(Form for requesting access to a record of a private body, in terms of section 53 of the Promotion of Access to Information Act 2 of 2000, read with the Regulations made under that Act.)
A. Particulars of the private body
| Private body | Edukinetics Practise (Pty) Ltd, trading as Edukinetics |
|---|---|
| Information Officer | Michelle Sickelmore |
| Address | 3 Protea Road, Protea Heights, Brackenfell, Western Cape, South Africa |
| hello@edukinetics.com | |
| Telephone | 082 307 1386 |
B. Particulars of person requesting access to the record
(a) The particulars of the person who requests access to the record must be given below.
| Field | Details |
|---|---|
| Full name and surname | ………………………………………………………………………………………………………… |
| Identity number | ………………………………………………………………………………………………………… |
| Postal address | ………………………………………………………………………………………………………… |
| Email address | ………………………………………………………………………………………………………… |
| Telephone number | ………………………………………………………………………………………………………… |
| Capacity in which request is made (if applicable, e.g. “parent/legal guardian of the child named in Part C”) | ………………………………………………………………………………………………………… |
C. Particulars of person on whose behalf request is made
This section must be completed ONLY if you are making this request on behalf of someone else, for example, as the parent or legal guardian of a child enrolled with Edukinetics.
| Field | Details |
|---|---|
| Full name and surname of the person on whose behalf the request is made | ………………………………………………………………………………………………………… |
| Date of birth (if a child) | ………………………………………………………………………………………………………… |
| Your relationship to that person | ………………………………………………………………………………………………………… |
| Proof of authority to act on their behalf (attached: yes / no) | ☐ Yes ☐ No |
D. Particulars of record
Provide as much detail as possible about the record(s) you are requesting, to help us locate them (for example, the type of record, date range, and any reference number).
| Field | Details |
|---|---|
| Description of the record or the subject matter | ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… |
| Reference number (if known) | ………………………………………………………………………………………………………… |
| Date(s) or date range of the record | ………………………………………………………………………………………………………… |
| Form of access requested | ☐ Copy of the record ☐ Inspection of the record ☐ Electronic copy (email) ☐ Other: ………………………………………………………………………………………………………… |
| If you are unable to read, view, or listen to the record in the form of access you requested, state the format in which you would prefer access | ………………………………………………………………………………………………………… |
E. Right that you are seeking to exercise or protect
If this request is for information other than your own or your child's personal information, briefly explain the right you are seeking to exercise or protect, and why the requested record is required for that purpose.
| ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… |
F. Notice of decision
How would you like to be notified of our decision on your request?
- ☐ By post to the postal address given in Part B
- ☐ By email to the email address given in Part B
- ☐ I will collect the response in person from Edukinetics's practice
G. Fees
A request fee and, where applicable, access/reproduction fees apply to this request, as set out in Edukinetics's PAIA Manual, unless you are requesting your own or your child's personal information (see the PAIA Manual, section 6.1, for when the standard fee does not apply). We will notify you of any fee payable before processing your request further.
H. Signature
| Signature of requester / person on whose behalf request is made | ………………………………………………………………………………………………………… |
|---|---|
| Date | ………………………………………………………………………………………………………… |
Please submit this completed form to hello@edukinetics.com, or by post or in person to 3 Protea Road, Protea Heights, Brackenfell, Western Cape, South Africa, marked for the attention of the Information Officer. See our PAIA Manual for the full process, applicable fees, and response timelines.