Kernu Põhikooli direktor                                                                    ......................................

Ene Rooma                                                                                               (kuupäev)

Avaldus

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(keda võtta vastu, millisesse klassi, mis ajast alates)

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               (allkiri)

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             (nimi)

                                                           AVALDUS

LISALEHT avaldusele             ISIKUKOOD.................................................

            1.1. PEREKONNANIMI       ......................................................................................

            1.2. EESNIMI                        ......................................................................................

            1.3. ISANIMI                         ......................................................................................

            2. Sünnikuupäev                      ......................................................................................

                                                           (päev, kuu, aasta)

            3. Sugu                                    M        N

            4. Sünnikoht/kodakondsus     ......................................................................................

            5. Rahvus                                ......................................................................................

            6. Emakeel/Kodune keel         .....................................................................................

            7. Õpilane tuli Kernu Põhikooli (asutuse nimetus/kodust I kl.)

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            8. Andmed vanemate kohta:

            8.1. EMA                                ......................................................................................

                                                           Eesnimi, perekonnanimi

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                                                           Kontakttelefon,  e-posti aadress

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            8.2. ISA                                  ......................................................................................

                                                           Eesnimi, perekonnanimi

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                                                           Kontakttelefon, e-posti aadress

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            8.3. HOOLDAJA                   ......................................................................................

                                                           Eesnimi, perekonnanimi

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                                                           Kontakttelefon, e-posti aadress

            9. Tegelik elukoht                    POSTIINDEKS....................... MAAKOND...............                           

                                                           VALD................AADRESS.........................................

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             9.1 Kodu kaugus koolist...................km .        Kasutab/ei kasuta ühistransporti

                                                           KODUNE TELEFON .................................................

            10. Alaline sissekirjutus            ......................................................................................

                                                           ......................................................................................

                                                           Kui erineb elukoha aadressist

            11. Esitatud dokumendid         11.1 avaldus                                        EI        JA

                                                           11.2 tervisekaart                                 EI        JA

                                                           11.3 .......klassi tunnistus                      EI        JA

                                                           11.4 väljavõte õp. raamatust                EI        JA

                                                           11.5 hinneteleht                                   EI        JA

                                                            11.6 sünnitunnistus                             EI        JA

            Kuupäev: ...............................

            Lisalehe täitnu allkiri.....................................Avalduse võttis vastu...........................