Form ECD-PTP 1

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Student Information Form -

Early Childhood Development Programs and Services - Prior to Prep

This form is completed by parents, in collaboration with the Head of Special Education Services
(or the appointed Case Manager)

Privacy Statement

The Department of Education and Training collects, uses and discloses a child’s personal information in accordance with the confidentiality provision in s.426 of the Education(General Provisions) Act 2006. Information on the child’s medical, developmental and educational status and historyis being collected, used or disclosedfor the purpose of determining eligibility to register for access to early childhood development programs and services. The information will be kept in a secure location and will only be accessed by relevant departmental personnel.The child’s information will not be given to any other person or external body unless consent has been provided or the department is permitted or required by law to use or disclose such information.Information given to the professionals or agencies listed below is for the purpose of informing their professional service to the child.

REGION:

STUDENT DETAILS:
Surname: / Given Name/s:
Date of Birth: / Male
Female
Home Address:
Parent Name: / Parent Name:
Contact Phone Number: / Contact Phone Number:
Address (if different to above): / Address (if different to above):
General Practitioner:
Contact Details:
Medical Specialist:
Contact Details:
OTHER ORGANISATIONS/AGENCIES:
Organisation/Agency / Programs/Services
Provided / Contact Person / Contact Details
Initials (Parent) / Date
I give permission for my child’s general practitioner and/or medical specialist to be contacted,and for relevant personal information to be shared if required, as part of the data and information gathering process, for application to access an early childhood development program or service. This may includediagnostic informationand information to support educational planning.
I give permission for the other agencies as named above to be contacted and for relevant personal information to be shared, if required, as part of the data and information gathering process to access an early childhood development program or service. This may include diagnostic information and information to support educational planning.
I am able/unable to attend sessions with my child at the early childhood development programin accordance with the ‘Early Childhood Development Programs and Services for Children with Disabilities - Prior to Prep’ (please discuss level of involvement with the Head of Special Education Services/case manager).

This form is signed below only when agreement is reached with the parent to progress with data collection for application to access an early childhood development program or service.

Parent: / Date:
Head of Special Education Services/Case Manager: / Date:
Guidance Officer (if applicable): / Date:

THIS FORM IS TO REMAIN ON THE STUDENT’S SCHOOL FILE

Uncontrolled copy. Refer to SMS-PR-015: Early Childhood Development Programs and Services for Children with a Disability - Prior to Prepat for master.

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