SIEBA New Zealand Signup Form

Fields marked with * are required.

Student Details
First name (as on passport)
*
Middle names (as on passport)
Last name (as on passport)
*
Preferred first name
Date of Birth .
The Education (Pastoral Care of International Students) Code of Practice 2016 requires that all students under the age of 10 must live with a parent for the duration of their enrolment at school in New Zealand.
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Country of Birth
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Gender
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Ethnicity
*
First Language
*
Overseas Address
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*

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Overseas phone number
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New Zealand mobile number
Email address
*
How long have you studied English
Years Months
Sporting Interests
Other:
Cultural Interests
Other:
Agency Details (Only applicable if you are an agent)
Agency
Agent Name
Contact Email
Previous Applications
What was the name of the last school you attended?
Have you applied to SIEBA New Zealand before?
If yes, when?
Have you studied in New Zealand before?
If yes, please state which school
Has your brother or sister enrolled at SIEBA New Zealand before?
Name
Year Attended
Travel Details
Arrival date (if available)
Passport number
Passport expiry
Student Visa number
Student Visa issued
Student Visa expiry
Parents/Caregivers Details
Mother/Caregiver 1 Details:
First name
*
Middle names
Last name
*
Relationship (Mother,Father,Guardian)
*
Occupation
Overseas address
*
*

*
Phone number
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Work number
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Mobile number
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Email address
*
Passport number
Father/Caregiver 2 Details:
First name
Middle names
Last name
Relationship (Mother,Father,Guardian)
Occupation
Overseas address




Phone number
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Work number
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Mobile number
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Email address
Passport number
Accommodation Details
The Education (Pastoral Care of International Students) Code of Practice 2016 requires that all students under the age of 10 must live with a parent for the duration of their enrolment at school in New Zealand.
Where will you be staying? *
Homestay Information
Letter to Homestay
Please paste in a short letter (below) to introduce yourself to your new host family. Tell them what you like, why you're coming to New Zealand any anything else you want them to know.
Important Homestay Considerations
Please include any important homestay requirements, such as vegetarian, or that you are allergic to cats etc. This information is used to help us choose the best homestay for you.
Parent/Designated Caregiver (DCG) Details
First name
Middle names
Last name
Relationship (Mother,Father,Aunt,Guardian)
Occupation
Overseas address




Phone number
Work number
Mobile number
Email address

Please note: A DCG must be a relative or close family friend of the family. This accommodation must be approved by SIEBA New Zealand prior to the student's arrival. Please provide a copy of the passport (and visa if applicable).

Medical Details
Do you wish to purchase insurance through the SIEBA? *

Insurance must cover travel and health for entire length of stay in New Zealand.

Insurance company
Insurance policy number
Insurance policy expiry
Medical Conditions
Do you have or have you ever had any of the following?
ADD/ADHD Asthma Back/Neck problems Glandular Fever Migraines Diabetes Hepatitis A, B or C Depression/Anxiety Heart Condition Mobility Issues Tuberculosis Food Allergies Eating Disorders Epilepsy Bee/Wasp Sting Allergy Any Mental Illness HIV or AIDS Medical/Metal Implants Learning Difficulties Behavioural Difficulties Allergies
Additional Medical Information
You must declare all other medical details. Withholding information may result in your contract being terminated.

The school WILL dispense any over the counter medications as it sees fit to students UNLESS specified above.
Current Medications
Allergies
Name of Doctor (in home country)
Phone number of Doctor
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Emergency Contact (If other than parent)
First name
Family name
Relationship
Phone number
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Address
Email address
Course Details
School Choices
Study Programme
When will you start?
Year Term Duration Terms
Start:
Finish:
Year/Subjects
Learning Difficulties
You must declare any learning difficulties you may have. Failure to notify of any difficulties may result in your enrolment being terminated.
Comments
Is there anything you would like to tell us?
Declarations

Please download print and sign the declaration form, then scan it and attach it below.

File Uploads
Passport
Your Photo
Last School Report
Insurance Certificate
Signed Declaration (see above)
*