St. Pius X Primary School

St Pius X School, Melville


Caregiver Information (either a designated caregiver or a parent living in New Zealand is compulsory) Please fill this form out and bring it with you to school

Full Name:

Address in New Zealand:




Will the student be intending to stay with the caregiver/parent?:

Current New Zealand Immigration Status:

Country of Origin:

Passport No.:

Health and Insurance

Health Comments:


Is medical insurance held?                             Yes/No

(a copy of the policy is required prior to commencement of study at St Pius X School) Full health and personal insurance can be arranged through the school

Medical Authority

I/We, the parents/caregivers/guardians of _________________  authorise and direct you to discuss any medical condition relating to the above student and also to release any file, notes or documentation relating to any medical consultation in regard to the above student to the Principal at St Pius X School, 57 Pine Avenue, Melville, Hamilton, New Zealand.

Parent / Legal Guardian Signature:                      Date:



The application form is to be supported with evidence of the following:

  • Copy of student's passport and visa
  • Copy of parent(s)/designated guardian(s) passport details including signature and passport photo and visa



I understand that if I make any false statements, or provide any false or misleading information, or have changed or altered the application form in any way, the application may be declined or my acceptance to the International Student Programme may later be revoked, and that I may also be committing an offence and liable to prosecution.


Further details of terms and conditions for studying at St Pius X School are available through our School prospectus and attached brochure, our website at ( or by contacting the school directly.


I understand the notes and questions in the application form, and have read and understood the conditions as outlined in the International Student Handbook provided by St Pius X School and I declare the information given about myself, my spouse/partner and any other guardian and any child or children it true and complete.


Parent / Legal Guardian Signature:                                Date:          



"St Pius X School has agreed to observe and be bound by the Code of Practise for the Pastoral Care of International Students published by the Ministry of Education.  Copies of the Code are available on request from this institution or from the New Zealand Ministry of Education website at".