Where Children Love to Learn

Tiny Tots, Playgroup, TK A, TK B & Primary Grades 1 - 6

Student Application Packet for Academic Year 2011/2012

* one application per child Materai required *

Pelangi School - Where children love to learn

Banjar Kumbuh, Mas, Ubud, Bali. Tel: +62082145247146 Email: office@pelangischoolbali.com Website: www.pelangischoolbali.com

APPLICATION FOR*
Entering Class Starting Date Childs Information Complete Name of Child Nickname Date of Birth Gender Nationality & Passport/KTP # Parents or Guardians of Child Father Name of Parents/Guardians Nationality ID / Passport Number Permanent Address Profession Current Address Telephone Number Email Childs Language First Language Languages Spoken : : : : : : : : Mother : : : Day: : : Month: Year: : : TT/Playgroup ____________________ TK A/B SD 1-6

: :
Beginner Intermediate Fluent Beginner Intermediate Fluent

Information on Siblings Names Ages School

* P l e a s e

a n s w e r

a l l

q u e s t i o n s

a s

f u l l y

a s

p o s s i b l e !

HEALTH
Doctors Name Doctors Address

INFORMATION
: : :

Doctors Telephone Number

List those persons who can be called in case of an emergency (at least one local in Ubud) Name : Address : Phone :

Name

Address

Phone

Name

Address

Phone

Is your child currently taking any medication?

* pls note that an additional Medication Permission Form is also required

Yes

No

Please list names of medications and instructions for administering them:

Does your child have any food allergies? If yes, please list allergies below:

Yes

No

_________________________________________________________________________________
Please explain what procedures must be taken in event of exposure: ________________________________________________________________________________

________________________________________________________________________________

HEALTH

INFORMATION
Yes No

Has your child ever been diagnosed with learning disabilities or had to follow a special educational program?

If yes, please give a brief explanation *continue on back of paper if necessary:

__________________________________________________________________________________

Does your child have any particular habits/behaviours or needs for special attention of which the teacher should be aware?

Yes

No

If yes, please give a brief explanation *continue on back of paper if necessary:

__________________________________________________________________________________

Does your child have any limitations participating in physical activities?

Yes

No

If yes, please give a brief explanation *continue on back of paper if necessary:

__________________________________________________________________________________

Has anyone in your family (not your child) ever been diagnosed with any of the following : Tuberculosis Typhoid Fever Asthma Epilepsy Yes Yes Yes Yes No No No No

If yes, please give details *continue on back of paper if necessary:

___________________________________________________________________________________

Does your child have any hearing difficulties? Does your child have any vision problems? Does your child have any allergies to insect bites?

Yes Yes Yes

No No No

If yes, please explain what steps need to be taken in the case of your child being bitten:

___________________________________________________________________________________

HEALTH
ILLNESS HISTORY

INFORMATION

Has your child ever been diagnosed with any of the following? If yes, please fill in the year of occurrence. Asthma Chicken pox Dengue fever Diabetes Epilepsy : ________________________________________ : ________________________________________ : ________________________________________ : ________________________________________ : ________________________________________

Severe Headaches : ________________________________________ Heart condition Tuberculosis Typhoid fever Measles Nose bleeds Other : ________________________________________ : ________________________________________ : ________________________________________ : ________________________________________ : ________________________________________ : ________________________________________

IMMUNIZATION HISTORY
Due to many diseases still prevalent & easily contracted within Bali, Pelangi School strongly encourages families to have their children fully immunized. If your child has been immunized, please fill in the date of last immunizations. Diphtheria/Tetanus/Pertussis Chicken Pox Measles/Mumps/Rubella Tetanus (every 10 years) : ____________________________ : ____________________________ : ____________________________ : ____________________________

Tuberculosis Typhoid (every 3 years) Hepatitis A Hepatitis B Polio Other

: ____________________________ : ____________________________ : ____________________________ : ____________________________ : ____________________________ : ____________________________

RELEASE OF LIABILITY

We the undersigned, parents/guardians of:

Hereby agree to the following: 1. I / we give permission for my / our child to participate in all field trips. 2. In the case of an accident on or off school property, Pelangi School does not accept liability for any resulting injury that may occur. 3. In the case of illness, Pelangi School does not accept liability for anything that may occur. 4. In the case of any damage or destruction caused by my / our child on or off the property of Pelangi School (including field trips), I / we accept full moral and financial responsibility.

This agreement remains in effect for the entire duration of the period my / our child is enrolled at Pelangi School.

Date and Place:

Signed,

Note: Please affix materai stamp here (Rp.6,000)

Note: Please affix materai stamp here (Rp.6,000)

(
Father / Guardian

(
Mother / Guardian

ACCEPTANCE OF TERMS OF ENROLMENT ACADEMIC YEAR 2011 / 2012

I,

Parent / guardian of hereby enroll my child at Pelangi for the academic year 2011/2012. I have read the attached Tuition Payment Policy including all rules and policies relating to payment. I understand and accept all terms contained within, and I agree to pay all required fees by the dates specified.

Place and Date :

Signed,

Note: Please affix materai stamp here (Rp.6,000)

Note: Please affix materai stamp here (Rp.6,000)

(
Father / Guardian

(
Mother / Guardian

TUITION PAYMENT POLICY

Further to the recent announcement of the school fees for next year, we would like to confirm that a 10% discount is available if this forthcoming years tuition fees are paid IN FULL by May 15th 2011; you also have the ability to lock in this discounted rate for as many years as you wish to pay at this time. Please request further information about this option from the Pelangi Office. Once paid, you will not have to pay any increased tuition or building fees for those years paid in advance. For those not wishing, or unable to take advantage of the discount offer, the published tuition rates must be paid in full by June 15th 2011.

Division of Quarterly Terms

Starting in the 2011/2012 year, Pelangi School will separate the school year into four quarters based upon total number of school days divided equally. Each quarter has approximately 47 school days.
payment due date

Qtr 1 Qtr 2 Qtr 3 Qtr 4

15 August, 2011 31 October, 2011 30 January, 2012 23 April, 2012

21 October, 2011 27 January, 2012 20 April, 2012 27 June, 2012

June 15th, 2011 October 7th, 2011 January 13th, 2012 March 30th, 2012

Discount Policies
30% discount offered to all students with both parents holding Indonesian passports. For families enrolling more than one child at the school, and paying full tuition (not on scholarship), a 15% discount on tuition for any additional siblings. Discounts are for Tuition only & DO NOT apply to Enrolment or Facilities & Resources Fees. Discounts apply to the tuition of the youngest sibling(s).

Late Payment Policies & Fees

Monthly payment plans are possible. For this payment plan, there will be an additional 5% levied to tuition and fees due, please discuss this option with the Pelangi Office. If tuition fees are not paid on time, a levy of Rp.250,000 will be assessed every week up to one month. If payment is still outstanding, the student will be asked to stay home until the tuition is paid.

Refund Policy
Enrolment, Facilities & Resources, and Tuition Fees are non-refundable. There will be no pro-rated tuition for students that leave due to sickness or holiday during the school year. The school hires staff and teachers based on the amount of children enrolled the school. We still need to pay our teachers for the entire school year.

Method of Payment
Payments are to be made by bank transfer or direct deposit to account: Bank : BRI Address of Bank : Cabang Ubud, Jl. Raya Ubud Account Number : 059001-000063-30-2 Beneficiary Name : YAYASAN CAHAYA PELANGI BALI Swift Code : BRINIDJA Note : (please mention childs name & grade, parents name) Payment receipts must be given to the school office staff within two days after payment has been made.
The tuition quoted in the registration documents is applicable for the 2011/2012 school year only.

TUITION & FEES FOR ACADEMIC YEAR 2011/2012

LOWER SCHOOL (PGTTTKA)
Tiny Tots
Item Quarter 1 Tuition Quarter 2 Tuition Quarter 3 Tuition Quarter 4 Tuition Notes Quarterly Quarterly Quarterly Quarterly When Due 13-Jun-11 7-Oct-11 13-Jan-12 30-Mar-12 Amount Rp. 2,750,000 2,750,000 2,750,000 2,750,000 11,000,000 2,000,000 1,000,000

Sub Total Annual Tuition & Academic Fees : One One Time Enrolment Fee* : Time 13-Jun-11 Annual Facilities & Resources Fee : Annual 13-Jun-11

Playgroup
Item Quarter 1 Tuition Quarter 2 Tuition Quarter 3 Tuition Quarter 4 Tuition Notes Quarterly Quarterly When Due 13-Jun-11 7-Oct-11 Amount Rp. 5,000,000 5,000,000 5,000,000 5,000,000 20,000,000 2,000,000 2,000,000

Quarterly 13-Jan-12 Quarterly 30-Mar-12 Sub Total Annual Tuition & Academic Fees : Annual One Time 13-Jun-11 13-Jun-11

Annual Facilities & Resources Fee : One Time Enrolment Fee* :

Kindergarten (TK) A
Item Quarter 1 Tuition Quarter 2 Tuition Quarter 3 Tuition Quarter 4 Tuition Notes Quarterly Quarterly When Due 13-Jun-11 7-Oct-11 Amount Rp. 5,250,000 5,250,000 5,250,000 5,250,000 21,000,000 4,000,000 2,000,000

Quarterly 13-Jan-12 Quarterly 30-Mar-12 Sub Total Annual Tuition & Academic Fees : Annual One Time 13-Jun-11 13-Jun-11

Annual Facilities & Resources Fee : One Time Enrolment Fee* :

UPPER SCHOOL (SD)

Kindergarten (TK) B * located in SD campus
Item Quarter 1 Tuition Quarter 2 Tuition Quarter 3 Tuition Quarter 4 Tuition Notes Quarterly Quarterly Quarterly When Due 13-Jun-11 7-Oct-11 13-Jan-12 Amount Rp. 6,750,000 6,750,000 6,750,000 6,750,000 27,000,000 6,000,000 2,000,000

Quarterly 30-Mar-12 Sub Total Annual Tuition & Academic Fees : Annual One Time 13-Jun-11 13-Jun-11

Annual Facilities & Resources Fee : One Time Enrolment Fee* :

Primary School (SD) Grades 1 6 * located in SD campus

Item Quarter 1 Tuition Quarter 2 Tuition Quarter 3 Tuition Quarter 4 Tuition Notes Quarterly Quarterly When Due 13-Jun-11 7-Oct-11 Amount Rp. 8,000,000 8,000,000 8,000,000 8,000,000 32,000,000 7,000,000 2,000,000

Quarterly 13-Jan-12 Quarterly 30-Mar-12 Sub Total Annual Tuition & Academic Fees : Annual One Time 13-Jun-11 13-Jun-11

Annual Facilities & Resources Fee : One Time Enrolment Fee* : * Additional Fee Rules:

One-Time Enrolment Fee: For all new students, must be paid upon enrolment by June 13, 2011. Annual Facilities & Resources Fee: Incredibly important to the livelihood of the school, this annual fee is what maintains and upgrades the Pelangi infrastructure. This fee is required by all students. Please support the growth of Pelangi School by paying this fee upon enrolment by June 13, 2011. More notes: The Facilities & Resources Fee must be paid in the full upon enrolment. If a student attends Pelangi School for two quarters or less, they will be responsible to pay 50% of these fees. If a student attends Pelangi for more than three quarters within one school year, they will be responsible to pay 100% of the Facilities and Resources Fees. All students from Play Group to SD are required to wear the Pelangi School Uniforms. Pelangi tshirts, knapsacks & shorts of all sizes may be purchased at the Pelangi school office. Lunch and snack are not provided. Lunch & snack for all year groups can be pre-ordered and purchased from the Warung Bamboo located at the SD campus or children can bring a bag lunch/snack from home (PEANUT FREE). Scholarships are based on criteria determined by Pelangi School. If you wish to request financial assistance, please request a scholarship form at the office. THERE ARE NO REFUNDS FOR TUITION & FEES AT ANYTIME.

Yayasan Cahaya Pelangi School: Banjar Kumbuh, Mas, Ubud, Bali. Tel: Tel: +62082145247146 or +623618504569 Email: office@pelangischoolbali.com Website: www.pelangischoolbali.com