Parent Disclosure Statement
STUDENT DETAILS (Please complete all details in BLOCK LETTERS):
SURNAME: ______FIRST NAME/S: ______
D.O.B. ______COUNTRY OF BIRTH: ______SEX: M F
ADDRESS: ______SUBURB: ______P/CODE______
HOME PH: ______MOBILE PH: ______
EDUCATIONAL YEAR OF ENTRY: Year Prep Ungraded
LUI Number (If in Year 10 or above): ______
Is a language other than English spoken at home by student/parent or guardian? Yes No
If Yes, please specify: ______
Are there any relevant language issues which will impact on the child’s participation at school? Yes No
______
______
Does your child identify as: Aboriginal Torres Strait Islander Neither
Date of Application (today): ______Proposed Starting Date: ______Date Rec’d at Admin ______
Previous School/s and/or Programs: (please attach relevant documentation e.g. School reports) ______
PARENT DETAILS (Please complete all details in BLOCK LETTERS):
Mother/Guardian 1 Name (in full): ______
Home Address: ______Suburb: ______P/code:______
HM Ph: ______MOBILE: ______WORK: ______
Postal Address: ______
Email: ______
Occupation: ______
Highest Schooling Level: Year 12 11 10 9 or below
Highest Tertiary Level: Degree or above Advanced Diploma/Diploma Cert 1 to 4 Other ______
______
Father/Guardian 2 Name (in full): ______
Home Address: ______Suburb: ______P/code:______
HM Ph: ______MOBILE: ______WORK: ______
Postal Address: ______
Email: ______
Occupation: ______
Highest Schooling Level: Year 12 11 10 9 or below
Highest Tertiary Level: Degree or above Advanced Diploma/Diploma Cert 1 to 4 Other ______
______
Emergency Contacts (other than Parent/Guardian):(WE REQUIRE 2 CONTACTS WITH CURRENT PHONE NUMBERS)
Contact 1: ______Relationship to Student: ______
HM Phone: ______MOBILE PH: ______
Email: ______
Address: ______Suburb: ______P/Code:______
Contact 2: ______Relationship to Student: ______
HM Phone: ______MOBILE PH: ______
Email: ______
Address: ______Suburb: ______P/Code:______
FAMILY INFORMATION
Names and ages of siblings: ______
______
Court Orders:
Are there any relevant Court Orders/Custody arrangements in place in respect of this Application? Yes No
Please give relevant details and attach copies of documents: ______
______
Family Beliefs/Practices:
Are there any religious/philosophical beliefs/practices which will affect your child’s participation at school? Yes No
Please give details ______
______
MEDICAL/HEALTH INFORMATION:
Does your child/family have Private Health cover? Yes No
Name of Fund: ______Fund No: ______
Medicare No: ______(this is important information for the school)
Family Doctor/Medical Centre: ______Ph: ______
Address: ______
Vaccinations: Full Partial None Chicken Pox Hepatitis B HPV
Tetanus: Current Yes No Date of last injection: ______
Does your child have any relevant medical/health issues (including physical difficulties/impairments/allergies/current treatments) that may impact upon their learning at school? Please give details and attach documentation if relevant.
______
Does your child have any special requirements regarding the above information the school should be aware of? Yes No
Details:______
Relevant Dietary and/or Allergy requirements: ______
MEDICAL CONSENT AND INDEMNITY FORM:
In consideration of your acceptance of my child ______into the Blackall Range Independent School, I ______(Parent/guardian):
- Authorise you to seek on my behalf all, or any, medical treatment that you may consider necessary to expedient for the said child during the times he/she is in your charge.
- Agree to indemnify and keep indemnified Blackall Range Independent School, and Staff, against any claims that may arise out of any accident, incident, damage or injury involving the said child during the times he/she is in your charge.
Full Name: ______
Signature: ______Date: ______
Witness:
Full Name: ______Date: ______
Signature: ______
DEVELOPMENTAL OR LEARNING INFORMATION:
Are there any developmental/educational issues in relation to your child that the school should be aware of? Yes No
Please give details:
______
Has your child attended any Specialist Services? Yes No (examples: Speech Therapy, Occupational Therapy etc)
Please give Contact details:
______
MEDIA AND/OR WEBSITE CONSENT AND INDEMNITY:
I ______(Parent/Guardian)
DO DO NOT (Tick one)
give permission for my child’s photo or presence to be placed upon the School’s website if such opportunity arises through the publication of school newsletters/projects etc. I agree to indemnify and keep indemnified the school against any claims that may arise out of any incident in relation to this situation.
Signed: ______Date: ______
Witness (Name in Full): ______
Signature: ______Date: ______
CONDITIONS OF ENROLMENT AND RETENTION:
- You must inform the School at any time when your child does not attend (Required information for annual attendance reporting)
- Students are to abide by all School Rules.
- The School is to be advised of any medical problems/special medication required by the student. The Principal and/or First Aid Officer is authorised to act on behalf of the parent in a medical or other emergency if the parent cannot be contacted.
- The School is to be advised of any learning difficulties or other disabilities the student is currently experiencing.
- Parents are expected to co-operate with the School concerning general policy, matters of discipline (rules), attendance etc. The Policies, Rules and Regulations may be altered or added to any time by announcement at School assembly and publishing in the school’s newsletter.
- Parents are expected to keep their child at home while they are suffering from a cold or other infectious or contagious conditions. If, in the event of a child being diagnosed with a notifiable disease, the Parent is expected to notify the school immediately.
- Parents are expected to remove their child from the School if she/he becomes seriously ill.
- The Principal (or Principal’s nominee) reserves the right to discipline, suspend or expel any student whose attitude or behaviour is not conducive to the School’s Ethos.
SCHOOL FEES:
- By accepting enrolment, parents/guardians accept responsibility for the payment of school fees which include tuition fees, school community levy, and any other fees and expenses required by the school. Please note that the Parent/guardian who is signatory to this document is ultimately responsible for the payment of school fees as described above.
- Fees are payable a term in advance (unless a payment plan agreement has been entered into with the Business Manager) and payment must be made by the due date noted on the Family’s Term Invoice.
- Any fees outstanding for payment are recoverable and may incur an extra interest charge. At Blackall Range Independent School we engage the services of a Debt Collection Agency to undertake such services. Parents/guardians are expected to familiarise themselves with the School’s current Fee Schedule which outlines the above.
- Where tuition fees remain unpaid and no arrangement has been made for payment, then a child’s enrolment at the School may be withdrawn.
- The School reserves the right to review any fees charged and will notify you accordingly.
PRIVACY – STANDARD COLLECTION NOTICE:
- The Blackall Range Independent School collects personal information, including sensitive information about students and parents or guardians before and during the course of a student’s enrolment at the school. The primary purpose of collecting this information is to enable the School to provide schooling for your child.
- Some of the information we collect is to satisfy the School’s legal obligations, particularly to enable it to discharge its duty of care.
- Certain laws governing or relating to the operation of schools require that certain information be collected. These include Public health and Child Protection laws.
- Health information about students is sensitive information within the terms of the National privacy Principles under the Privacy Act. We may ask you to provide medical reports about your child from time to time.
- The school from time to time may need to disclose student information to others for administrative and educational purposes. This includes other school, government departments, medical practitioners and people providing services to the school including specialist visiting teachers.
- If we do not obtain the information referred to above we may not be able to enrol or continue the enrolment of your son/daughter.
- On occasions information such as student activities and other news may be published in school newsletter, magazines and on our website.
Privacy – standard collection notice cont....
- Parents may seek access to personal information collected about them and their/son/daughter by contacting the school. Students may also seek access to personal information about themselves. However, there will be occasions when access is denied. Such occasions would include where access would have an unreasonable impact on the privacy of others, where access may result in a breach of the school’s duty of care to the pupil, or where students have provided information in confidence.
- We will not disclose your personal information to other parties for their own marketing purposes.
- We may include your contact details in a class list and/or school directory.
- If you provide the school with the personal information of others, such as doctors or emergency contacts, we encourage you to inform them that you are disclosing that information to the school and why.
- School Internet and email activity are periodically analysed to verify security. Any inappropriate usage of school internet services will be investigated and acted upon accordingly.
SIGNATURES:
By signing below you agree that you have read, understood and will abide by the requirements contained in the Blackall Range Independent School’s Enrolment form.
Signed: ______(PARENT/GUARDIAN)
Full Name: ______
Date: ______
Signed: ______(PARENT/GUARDIAN)
Full Name: ______
Date: ______
CHECKLIST: WHAT TO BRING WITH YOU TO SCHOOL ADMINISTRATION:
Completed and Signed Enrolment Form
Supporting documentation – Birth Certificate, medical information, Court orders etc
Fees due and Payable - $100 Refundable Security Deposit per student/ $100 Non-refundable Enrolment Fee per student/ Term fees
Blackall Range Independent School
Parent Disclosure Statement – Formal Enrolment 2016