Student Enrolment Form

First name: *

Family name: *

Middle name(s):

Date of birth: *

Email Address

Phone Number

GenderMaleFemaleOthers

Home Address *e.g. 40 Lorne St, Fawkner VIC, Australia

Postcodee.g. 3060

Student’s Mainstream School Name:

Student’s Mainstream Year Level:

Student's Residency Status

Australian citizen/Permanent residentFee paying international student Other

If Other, please specify:

Parent/Guardian Details

Name of Parent/Guardian:

Relationship to student:

Work phone:

Mobile phone: *

Email: *

Emergency Contact Details

(only complete if different from parent/guardian details)

Emergency contact name:

Emergency contact phone:

Relation to student:

Medical Information

Does your child suffer from any medical condition? (e.g. asthma, epilepsy, allergies etc.)?YesNo

If Yes, please specify and provide a medical plan (e.g. asthma, anaphylaxis etc.)

Is your child currently on any medication?YesNo

If Yes, please specify:

Privacy Collection Notice - Protecting your privacy and sharing information:

The information about your child and family collected through this enrolment form will only be shared with school staff who need to know to enable the community language school and Department of Education and Training (Department) to educate or support your child, or to fulfill legal obligations including duty of care, anti-discrimination law and occupational health and safety law. The information collected will not be disclosed beyond the Department without your consent, unless such disclosure is lawful. For more about information sharing and privacy, see the Department’s privacy policy at:

Parent/Guardian Privacy Consent and Declaration

I confirm that the information provided on this enrolment form is true and correct and I acknowledge and agree to the terms and conditions of enrolment accompanying this enrolment form. I consent to:

• the collection of my child’s health and personal information by the community language school;
• the community language school disclosing my child’s personal information contained in this enrolment
form to the Department of Education and Training for data verification and funding purposes;
• the Principal or teacher (where the Principal or teacher in charge is unable to contact me) to
administer such first aid to my child as the Principal or staff member may consider being reasonably
necessary including disclosing personal and health information to professional third parties in the
event of a medical emergency

Name of Parent/Guardian:

Date of Submission *