2AANSOEK OM TOELATING VIR 2018 // APPLICATION FOR ADMISSION FOR 2018

NOEMNAAM & VAN / FIRST NAME & SURNAMESTUDENTENOMMER (VIR KANTOORGEBRUIK)STUDENT NUMBER (FOR OFFICE USE)SELFOONNOMMER (STUDENT)CELLPHONE NUMBER (STUDENT)

R STUDENT / 1ST YEAR STUDENT 2DE JAAR STUDENT / 2ND

3DE JAAR STUDENT / 3RD

BELANGRIK / IMPORTANT

DIE VOLGENDE MOET U AANSOEK VERGESEL / THE FOLLOWING MUST BE ATTACHED TO YOUR APPLICATION

1. ID-foto / ID photograph (2)

2. Afskrif van u laaste rapport of matrieksertifikaat / Copy of the requisite rapport or matric certificate

3. Tjek of depositostrokie van u depositos betaal / Cheque or deposit slip of the deposits payable

4. 4 gewaarmerkte afskrifte van ID-dokument / 4 certified copies of identity document Dit is in u eie belang dat hierdie vorm volledig voltooi en gesertifiseerde afskrifte van

stawende dokumente ingesluit word. Indien enige vrae onbeantwoord gelaat word, gesertifiseerde afskrifte nie ingesluit is nie of die ooreenkoms nie onderteken is nie, sal dit ‘n vertraging veroorsaak, aangesien die vorm aan u teruggestuur sal word vir voltooiing. Gebruik asseblief swart ink en blokletters. / It is in your own interest to ensure that this form is completed in full and that certified copies of all supporting documents are enclosed. If any question is left unanswered or certified documents are not enclosed, or the agreement is not signed, it will cause a delay as the form will be returned to you for completion. Please write in black ink and use block letters.

Na voltooiing van vorm, faks / epos dit na 086 211 0579 / info@stellenboschrugbyacademy.co.za. Bring oorspronklike vorm en dokumente saam op registrasiedag / After you have completed the form, it must be faxed / emailed to 086 211 0579 / info@stellenboschrugbyacademy.co.za. B r i n g original form and documents along on registration day.

VOLTOOI DIE INLIGTING VOLLEDIG IN DUIDELIKE, LEESBARE DRUKSKRIF EN STUUR/FAKS DIT ASSEBLIEF TERUG. PLEASE COMPLETE THE FORM IN CLEAR, READABLE BLOCK LETTERS AND SEND/FAX IT BACK.

1. PERSOONLIKE INLIGTING / BIOGRAPHICAL PARTICULARS

VOLLE VOORNAME/FULL NAMESGEBOORTEDATUM/ DOB

HUISTAAL /HOME LANGUAGE

Foto / Photo

3AANSOEK OM TOELATING VIR 2018 // APPLICATION FOR ADMISSION FOR 2018

PASPOORT NR./PASSPORT NR.

STUDIE-/VERBLYFPERMIT STUDY/RESIDENTIAL VERVALDATUM/EXPIRY

DATE PERMIT NR./PERMIT NR.

2. SKOOL INLIGTING / SCHOOL RECORDNAAM VAN SKOOLNAME OF SCHOOL

GRAAD 12 JAARMATRIC YEAR

LEIERSPOSISIE(S) / LEADERSHIP POSITION(S)

GEM. % / AVG. %

3. NASKOOLSE AKTIWITEITE / ACTIVITIES SINCE MATRIC

AKTIWITEIT (BV. UNIVERSITEIT/KOLLEGE/OORSEE//WERK)ACTIVITY (E.G. UNIVERSITY/COLLEGE/ABROAD/EMPLOYED)

KWALIFIKASIEQUALIFICATION

JAARYEAR

IDENTITEITSNOMMER / ID Nr.

E-POS / E MAILHUISADRES/RESIDENTIAL ADDRESS

KODECODE

POSADRES/POSTAL ADDRESS KODECODE

ADRES VIR REKENING / ADDRESS FOR ACCOUNT KODE

CODEBEVOLKINGSGROEP / POPULATION GROUP

NASIONALITEIT /

KERKVERBAND / RELIGIONWAAR VAN SRA GEHOOR? / WHERE DID YOU HEAR OF

4. OUER/VOOG SE BESONDERHEDE / PARTICULARS OF PARENT/GUARDIAN

4.1 VADER / FATHERTITEL, VOORLETTERS EN VAN TITLE, INITIALS AND SURNAMEIDENTITEITSNOMMERIDENTITY NUMBER

BEROEP/ OCCUPATION WERKGEWER/ EMPLOYERHUIS TEL NR./ HOME TEL

NR.WERK TEL NR./ WORK TEL NR.

SEL NR. / CELL NR. HUWELIKSTATUS / MARRIAGE STATUS

E-POS ADRES / E-MAIL

4AANSOEK OM TOELATING VIR 2018 // APPLICATION FOR ADMISSION FOR 2018

5.

VERLANG U LOSIES IN ‘N STUDENTEHUIS VAN DIE RUGBYAKADEMIE? DUBBEL OF ENKEL?DO YOU REQUIRE ACCOMMODATION IN A

Ja/Yes

Nee/Nee

Dubbel/Double

Enkel/Single

6. SPELER-INLIGTING / PLAYER INFORMATION

SPEELPOSISIES / PLAYING POSITIONS

KEUSE 1 / CHOICE 1:

KEUSE 2 / CHOICE 2:

HOOGSTE VORIGE RUGBYPRESTASIES / PREVIOUS HIGHEST RUGBY ACHIEVEMENTS:

BESKRYWING / DESCRIPTION JAAR / YEARSKOOLSPAN / SCHOOL TEAMKLUB / CLUB

PROVINSIAAL / PROVINCIAL

NASIONAAL / NATIONAL

ANDER / OTHERAFRIGTER: NAAM, SELNR.COACH: NAME, CELLADDISIONELE INLIGTING / ADDITIONAL INFORMATION

GEWIG / WEIGHT LENGTE /LENGTH

4.2 MOEDER / MOTHER

TITEL, VOORLETTERS EN VAN TITLE, INITIALS AND SURNAMEIDENTITEITSNOMMER / ID NR.

BEROEP/ OCCUPATION WERKGEWER/

HUIS TEL NR./HOME TEL NR. WERK TEL NR./ WORK TEL NR.

SEL NR. / CELL NR. HUWELIKSTATUS / MARRIAGE STATUS

E-POS ADRES/ E-mail address

5AANSOEK OM TOELATING VIR 2018 // APPLICATION FOR ADMISSION FOR 2018

7. KLEREDRAG GROOTTES / CLOTHING MEASUREMENTS

BESKRYWING / DESCRIPTION GROOTTES / SIZE

KORTBROEKE / SHORTS S M L XL 2XL 3XL

T-HEMDE / T-SHIRTS S M L XL 2XL 3XL

SWEETPAK / TRACK SUIT S M L XL 2XL 3XL

8. MEDIESE INLIGTING / MEDICAL PARTICULARS

MEDIESE FONDSMEDICAL AID PLAN/ PLAN

FONDSNOMMERFUND NUMBER

STUDENT-LID NR (0-7) / STUDENT MEMBER NR (0-7)

HOOFLIDPRINCIPAL MEMBER

HOOFLID SELFOON NR. / PRINCIPAL MEMBER CELLPHONE NR.

HOOFLID ID NR. PRINCIPAL MEMBER ID NR.

BLOEDGROEP/ BLOOD GROUP

MEDIESE GESKIEDENIS / MEDICAL HISTORY

BESKRYWING / DESCRIPTION NEE / NO

JA / YES

SPESIFISEER OF OPMERKING / SPECIFY OR COMMENT

ALLERGIEË / ALLERGIES

VORIGE SIEKTES OF KWALE / PREVIOUS ILLNESSES/ DESEASESOPERASIES / OPERATIONS

DIABETES/ DIABETESSIELKUNDIGE OF GEESTESONGESTELDHEID / PSYCHOLOGICAL OR MENTAL DEFECTKOP EN NEK / HEAD AND NECK

HARTPROBLEME / HEART PROBLEMS

CHOLESTROL / CHOLESTROL

ANDER / OTHER

6AANSOEK OM TOELATING VIR 2018 // APPLICATION FOR ADMISSION FOR 2018

9. FINANSIES / FINANCES

BESKRYWING / DESCRIPTION BEDRAG/JAAR AMOUNT/YEAR

KEUSE () OPTION ()

RUGBYPROGRAM, MET DIPLOMA- KURSUS (Eta) /RUGBY PROGRAM WITH DIPLOMA COURSE (Eta)- Also other Diploma / Degree options

R63 300 (1st year)R55 000 (2’d year)

RUGBYPROGRAM, MET GAPJAAR- PROGRAM (SRA)/ RUGBY PROGRAM WITH GAPYEAR PROGRAM (SRA)

R58 000 (1st year)R55 000 (2’d year)

AFRONDINGSJAAR (3DE JAAR) /FINISHING YEAR (3RD YEAR) R27 500

AKKOMMODASIE -1 maaltyd/dag ingesluit /ACCOMMODATION – 1 meal/day included

R48 300 (DUBBEL/DOUBLE) OF/ORR51 700 ENKEL/SINGLE)

STUDENTEFONDS (STUDENTEHUISE) /STUDENT FUND (STUDENT HOUSES). Toer ingesluit.STUDENTEFONDS (PRIVAAT) / STUDENT FUND (PRIVATE). Tour included.

R5 000 OF/ORR3 000-00

TOTAAL / TOTAL

NOTE:

Maak seker dat u die Betalings-opsies vorm voltooi sodra u Bevestigingsbrief ontvang. / Make sure you complete the Payment Options form once you receive the Confirmation Letter.

DATUMS VIR BETALING / PAYMENT DUE DATES

BESKRYWINGDESCRIPTION

BESKRYWINGDESCRIPTION

DATUMDATE

BEDRAGAMOUNT

NIE-TERUGBETAALBARE REGISTRASIEFOOI / NON-REFUNDABLE REGISTRATION FEE

KURSUS / COURSE

VERBLYF / ACCOMMODATION

NA GOEDKEURING VAN AANSOEK / AFTER APPROVAL OF APPLICATION

R5 000-00OF / ORR10 000-00

*BETALING 1 /PAYMENT 1

BETALING VAN SPESIFIEKE KURSUS / PAYMENT OF SPECIFIC COURSE

8 JANUARIE /8 JANUARY

*BETALING 2 /PAYMENT 2

BETALING VAN VERBLYF, STUDENTEFONDS / PAYMENT OF ACCOMMODATION,STUDENT FUND

15 JANUARIE /15 JANUARY

* Deposito(s) word afgetrek. / Deposits are deducted.

BANKBESONDERHEDE / BANK DETAILS

REKENINGNAAM / ACCOUNT NAME STELLENBOSCH RUGBYAKADEMIE TRUSTBANK ABSATAK / BRANCH STELLENBOSCHTAKKODE / BRANCH CODE 632 005TIPE / TYPE TJEK / CHEQUEREKENINGNOMMER / ACCOUNT NUMBER 405 9811 640VERWYSING / REFERENCE STUDENT SE NAAM EN VAN / STUDENT NAME AND SURNAME

7AANSOEK OM TOELATING VIR 2018 // APPLICATION FOR ADMISSION FOR 2018

*TARIEWE IS ONDERHEWIG AAN VERANDERING. / RATES ARE SUBJECT TO CHANGES

8AANSOEK OM TOELATING VIR 2018 // APPLICATION FOR ADMISSION FOR 2018

10. OOREENKOMS / AGREEMENT

(PARAFEER ONDERAAN P. 6 - 10 / SIGN WITH INITIALS BELOW P. 6 – 10.)

ONDERNEMING DEUR OUER/VOOG EN AANSOEKER – ONS VERKLAAR: /DECLARATION BY PARENT/GAURDIAN AND APPLICANT - WE HEREBY DECLARE:

10.1 dat die besonderhede deur ons in die registrasievorm verstrek, waar en korrek is; / that the particulars furnished by us in this registration form are true and correct;

10.2 dat ons begryp dat die Stellenbosch Rugbyakademie, geregtig is om die inskrywing van die aansoeker onmiddellik te kanselleer, indien dit sou blyk dat die besonderhede in die aansoekvorm verstrek, onwaar of onjuis is; / that we fully understand that the Stellenbosch Rugby Academy is entitled to cancel the registration immediately, should it become apparent that any of the particulars of the applicant, furnished in this registration form,is/are untrue or incorrect;

10.3 dat ons die reëls, gedragskode en beleide soos deur die instellings vasgestel sal nakom en ons op hoogte sal hou daarvan; / that we will adhere to the rules/code of conduct and policies as set forth by the institutions;

10.4 dat ons onderneem om geen eis van enige aard teen die Stellenbosch Rugbyakademie of enige werknemer/kontrakteur van die instellings in te stel nie en om op geen wyse hoegenaamd die instellings aanspreeklik te hou vir enige skade of verlies wat ons persoonlik of aan eiendom van my mag ly en wat regstreeks of onregstreeks spruit uit die aansoeker se deelname gedurende sy studietydperk aan enige aktiwiteit van watter aard ook al, wat te doen het met my studie/opleiding/sport/vervoer/ontspanning van enige aard, hoe sodanige skade/verlies ook al mag ontstaan en dat hy aan enige van die gemelde bedrywighede op sy eie verantwoordelikheid sal deelneem en die risiko daaraan verbonde vrywillig aanvaar; / that we undertake not to institute any claim, of whatever kind against the Stellenbosch Rugby Academy or against any employee/contractor nor in any way whatever to hold the Stellenbosch Rugby Academy liable for any damage or loss whatever which the applicant may incur/suffer personally or in property of mine and which directly or indirectly arises from his participation during my period of study in any activity, of whatever kind, having to do with his studies/training/with sport/transport or recreation of whatever kind, however such damage or loss may come about, and that he will participate in any such activity on my own responsibility and will accept of my own free will the risk attaching thereto;

10.5 dat ons verder onderneem om, indien die aansoeker van losiesgeriewe wat deur die Stellenbosch Rugbyakademie verskaf word gebruik maak, nie die instansie of enige werknemer/kontrakteur van die instansie aanspreeklik te hou vir enige skade of verlies wat die aansoeker aan sy persoon of sy eiendom mag ly wat regstreeks of onregstreeks spruit uit inbraak en/of diefstal tydens sy verblyf op die eiendom van die instansie nie; / In the event of me making use of the accommodation provided by The Stellenbosch Rugby Academy, we further undertake not to institute any claim, of whatever kind against the Stellenbosch Rugby Academy or against any employee/contractor nor in any way whatever to hold the Stellenbosch Rugby Academy liable for any damage or loss whatever which the applicant may incur/suffer personally or in property of mine and which directly or indirectly arises from burglary and/or theft whilst he is living on the property of the Institution.

9AANSOEK OM TOELATING VIR 2018 // APPLICATION FOR ADMISSION FOR 2018

10.6 dat ons die Stellenbosch Rugbyakademie magtig om, indien die aansoeker dringende mediese behandeling sou benodig, geskikte mediese hulp te verkry en dat ons die verantwoordelikheid vir die betaling van die koste so aangegaan aanvaar / that we authorise the Stellenbosch Rugby Academy in the event of the applicant requiring urgent medical treatment to get appropriate medical assistance and that we accept responsibility for the payment of the costs thus incurred;

10.7 dat indien ons hierdie ooreenkoms kanselleer voor datum van registrasie, ons enige en/of alle registrasiegelde wat in terme van hierdie aansoek betaal is, verbeur. / That if we cancel this agreement before date of registrastion, we would forfeit any and/or all registration amounts that was paid in terms of this application.

10.8 dat ons ons verbind tot die stiptelike betaling van a lle g el d e soos op hierdie registrasievorm aangedui, selfs al sou die aansoeker sy kursus staak of ‘n besering opdoen / that we undertake to pay punctually al l fees as mentioned in this registration form, also in case of applicant’s cancellation of course or injury;

10.9 dat ons, indien die aansoeker sy studies of verblyf sou staak, ons steeds verbind is tot die stiptelike betaling van enige uitstaande gelde. Alle sodanige uitstaande gelde sal onmiddellik opeisbaar en betaalbaar wees en sal direk aan die Stellenbosch Rugbyakademie Trust betaalbaar wees; / that in the event of us terminating the applicants studies or accommodation, we undertake to pay punctually all fees. All outstanding fees will become due and payable immediately and shall be paid directly to the Stellenbosch Rugby Academy Trust.

10.10 dat ons voorts onderneem om alle regskoste, op prokureur en eie kliënt skaal, te betaal indien ons sou versuim om enige plig ten opsigte van die betaling in 10.7, 10.8 en 10.9 genoem na te kom / that we furthermore undertake to defray all legal costs arising in the event of our failure to discharge any duty relating to the payments mentioned in 10.7,10.8 and 10.9 above.

10.11 Dat ons begryp dat die student gevra kan word om die Stellenbosch Rugbyakademie dadelik te verlaat indien betalings agterstallig is, sy deurlopende bywoning van alle aktiwiteite nie 80% is nie, of hy nie aan die vereiste gedrag of kriteria vir prestasie en die kursus voldoen nie. Dit beteken hy verbeur sy kwalifikasie en is steeds verantwoordelik vir stiptelike betaling van alle gelde. / That we understand that a student can be asked to immediately leave the Stellenbosch Rugby Academy should payment of fees are not up to date, he not achieve an average attendance of 80% for all activities offered during the year not achieve the stipulated behaviour or criteria for successful completion of a course/subject. The student does not obtain his qualification and no course fees will be refunded.

10.12 Dat die aansoeker onderneem om slegs vir die spanne van Stellenbosch Rugbyakademie, Universiteit van Stellenbosch of WPRFU te speel / that the applicant undertakes to play for the teams of Stellenbosch Rugby Academy, University of Stellenbosch of WPRFU only.

10.13 Student ontvang nie sy kwalifikasie of sertifikate solank gelde nie ten volle betaal is nie. / A

student does not receive his qualification or certificates if his fees are not paid in full.

10AANSOEK OM TOELATING VIR 2018 // APPLICATION FOR ADMISSION FOR 2018

10.14 Die aansoeker aanvaar dat hy deur die ondertekening van hierdie ooreenkoms homself bind as mede-aanspreeklike en sal gesamenlik en of afsonderlik, saam met die ander mede-ondertekenaars, aanspreeklik wees vir die totale bedrag verskuldig. / The applicant accepted that by signing this agreement, he binds himself as co-accountable and will in joint and or together with the other co-signatories, be liable for the total amount due.

Geteken te/signed on ______________________________ op /at

_________________________________.20___.

___________________________________ __________________________________HANDTEKENING VAN AANSOEKER NAAM EN VAN IN DRUKSKRIF / SIGNATURE OF APPLICANT PRINT NAME AND SURNAME

___________________________________ __________________________________HANDTEKENING VAN VADER / VOOG NAAM EN VAN IN DRUKSKRIF / SIGNATURE OF FATHER / GAURDIAN PRINT NAME AND SURNAME

____________________________________ __________________________________HANDTEKENING VAN MOEDER / VOOG NAAM EN VAN IN DRUKSKRIF /SIGNATURE OF MOTHER / GAURDIAN PRINT NAME AND SURNAME

___________________________________ __________________________________HANDTEKENING VAN GETUIE NAAM EN VAN IN DRUKSKRIF /SIGNATURE OF WITNESS PRINT NAME AND SURNAME

___________________________________ __________________________________HANDTEKENING VAN GETUIE NAAM EN VAN IN DRUKSKRIF /SIGNATURE OF WITNESS PRINT NAME AND SURNAME

Geteken te/signed on ______________________________ op /at _________________________________

20___.

_____________________________________ __________________________________NAMENS STELLENBOSH RUGBYAKADEMIE NAAM EN VAN IN DRUKSKRIF /ON BEHALF OF STELLENBOSCH RUGBY PRINT NAME AND SURNAMEACADEMY