Currently we deliver to Somerset West, Stellenbosch, Strand & Gordons Bay.
(In future we hope to expand and go national.)
Personal Details:
Parent Name & Surname : …………………………………………………..……………………………………………………..
Child Name & Surname : …………………………………………………..……………………………………………………..
Child’s DOB : …………………………………………………..……………………………………………………..
Child’s School : …………………………………………………..……………………………………………………..
Child’s Grade, Class # & Teacher: …………………………………………………..……………………………………………………..
Contact details : …………………………………………………..……………………………………………………..
Does your child have any food allergies / intolerance's? YES NO
If Yes, please specify
…………………………………………………..……………………………………………………..
Is your child overweight? YES NO
Is your child underweight? YES NO
Do you consider your child a “difficult” eater? YES NO
If Yes, please indicate why
…………………………………………………..……………………………………………………..
Does your child have breakfast every morning? YES NO
Please specify what your child eats for breakfast
…………………………………………………..……………………………………………………..
Does your child take in enough fluids every day? (The norm is at least 500ml water / day) YES NO
Which fluids does your child drink regularly? (Circle where applicable)
Water Fruit Juice Cooldrink Carbonated Cooldrink Tea Rooibos Tea Milk
Is your child Halaal? YES NO
Does your child struggle to concentrate? YES NO
Is your child generally over active? YES NO
Does your child have mood swings (i.e. very energetic and bully the one moment and grumpy the next moments)? YES NO
Does your child have sleeping problems? YES NO
If Yes, please specify
…………………………………………………..……………………………………………………..
Do you feel that your child eats a healthy, balanced diet? YES NO
Where do you see room for improvement?
…………………………………………………..……………………………………………………..
Yes, I want my child to participate in this program…
Name of child :……………………………………………………
Grade :…………………………......………......….............
Name of Parent(s):……………………………………………
Signed :………………………….....…………...................
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