Student Enrolment Application Form

Student Enrolment Application Form

Student Enrolment Application Form

  • Specialist Primary School (No. 2085)
  • Centre of Excellence

This application is for the purpose of registering interest in a position at Insight Education Centre for the Blind & Vision Impaired (Insight Education Centre) and the opportunity to progress through the enrolment process to determine the most suitable program for you.

INSTRUCTIONS

Please complete all fields of the student enrolment form to the best of your knowledge.

REGISTRATION TO ENROL INCURS AN ENROLMENT FEE :

  • $55 (no GST) for the Specialist Primary School
  • $55 (including GST) for the Centre of Excellence – Hugh Williamson Life Management Program
  • $10(including GST) for the Centre of Excellence – Insight Out Mobile Classroom Program

Please return this application and payment of the Enrolment Fee to:

Insight Education Centre for the Blind & Vision Impaired

PO Box 983

Berwick VIC 3806

OFFICE USE

Interview held with: / Date of Interview:
Application Paid (date): / Receipt No.:
Entry Fee / Deposit Paid (date):
Student Number: / Date of Offer:
Student Details
Student Surname
Student Given Name/s
Preferred Name / Date of Birth / / /
Gender / Male Female / Religion
Country of Birth / Nationality
Language/s other than English spoken at home / Main language spoken at home
Is the Student of Aboriginal or
Torres StraitIslander Origin / No Yes, Aboriginal / Yes, Torres Strait Islander Both Aboriginal & Torres Strait Islanders
Position in the family
Names of Siblings currently attending Insight
Names of Siblings previously attended Insight
With whom does the student mostly reside / Both parents Mother Father Guardian
Student’s Residential Address
Postcode:
Enrolment Details
Current Year Level / Pre-school Primary school, Year Level: . Secondary school, Year Level: .
Desired Entry Level SPS / Primary School, Year Level: .
Attendance Frequency / Full Time Part Time: number of days in attendance (1-4): .
Preferred Days in Attendance / Monday Tuesday Wednesday Thursday Friday
Other Program / Hugh Williamson Foundation Life Management Program (please nominate the program below):
Support Skills Life Transition Program Early Learning & Parent Support
Mobile Classroom NILP
Current School / Pre-school
Current School address
Postal Address
Contact Name / Telephone
Name of Visiting Teacher (VT) (or other Education Advisor)
Contact details for VT (phone) / (email)
Parent / Guardian Details
Mother/Female Guardian
Title / Given Name/s
Family Name
Relationship to Student
Country of Birth
Primary language/s spoken at home
Interpreter required / Yes No
Correspondence sent to: / Mother/Female Guardian Both
Email Address
Home Address
Postal Address / Same as above, or:
Home Telephone No
Mobile No
Employment Details (Required by the Government)
Employer
Occupation
Employer Phone No
Category/Classification / Senior management in large business organisation, government administration and defence, and qualified professional
Other business manager, arts/media/sportsperson and associated professional
Tradesman/woman, clerk and skilled office, sales and service staff
Machine operator, hospitality staff, assistant, labourer and related worker
Not in paid work in the last 12 months Not stated or unkown
Education Details
Highest year of Primary or Secondary School completed / Year 12 or equivalent Year 11 or equivalent
Year 10 or equivalent Year 9 or equivalent or below
Highest Qualification level completed / Bachelor degree or above Advanced Diploma/Diploma
Certificate I to IV (including trade certificate) No non-school qualification
Parent / Guardian Details
Father/Male Guardian
Title / Given Name/s
Family Name
Relationship to Student
Country of Birth
Primary language/s spoken at home
Interpreter required / Yes No
Correspondence sent to: / Father/Male Guardian Both
Email Address
Home Address
Postal Address / Same as above, or:
Home Telephone No
Mobile No
Employment Details (Required by the Government)
Employer
Occupation
Employer Phone No
Category/Classification / Senior management in large business organisation, government administration and defence, and qualified professional
Other business manager, arts/media/sportsperson and associated professional
Tradesman/woman, clerk and skilled office, sales and service staff
Machine operator, hospitality staff, assistant, labourer and related worker
Not in paid work in the last 12 months Not stated or unkown
Education Details
Highest year of Primary or Secondary School completed / Year 12 or equivalent Year 11 or equivalent
Year 10 or equivalent Year 9 or equivalent or below
Highest Qualification level completed / Bachelor degree or above Advanced Diploma/Diploma
Certificate I to IV (including trade certificate) No non-school qualification
Custodial Arrangements
Are there any custody restrictions applicable to this student? / Yes (please detail below) No
Please describe:
Is there an Access Alert for your child? / Yes (please detail below) No
If Yes, please describe:
Please attach a copy of the relevant section from the Family Court Order / / Attached
Persons (other than parent / guardian) permitted to collect the student from Insight
Name / Relationship
1
2
3
4
Student’s mode of transport to and from school / Private Car
Insight School Bus (please complete Registration for School Bus Services Form)
Taxi Company
Walking
Public Transport (if yes, please detail route below)
Emergency Contacts
Person 1 / Person 2
Name
Relationship
Mobile Phone No
Home Phone No
Work Phone No
Emergency Contacts (continued)
Person 3 / Person 4
Name
Relationship
Mobile Phone No
Home Phone No
Work Phone No
Medical Information
VISION IMPAIRMENT
Diagnosed Vision Impairment / (Please attach a copy of the report)
Best Corrected Acuity
Field Restrictions
Please attach / Ophthalmologist / Optometrist report
EVAC (Educational Vision Assessment Clinic) assessment
Does your child suffer from any allergies / No Yes (Please attach a copy of the Allergy Management Plan & Medication Plan)
Does your child take any medication / No Yes (Please attach a copy of the Medication Plan)
Does your child suffer from asthma / No Yes (Please attach a copy of the Asthma Management Plan)
Does your child suffer from anaphylaxis / No Yes (Please attach a copy of the Anaphylaxis Management Plan)
Medicare Number / Expiry Date
Private Health Cover / No Yes
If Yes, Fund Name / Member Number
In the event of illness or injury to my child whilst at school, on an excursion, or travelling to or from school, I authorise the Teacher-in-charge of my child, where the Teacher is unable to contact me, or it is otherwise impracticable to contact me to:
  • Arrange for my child to receive such medical or surgical attention as may be deemed necessary by a medical practitioner,
  • Administer such first aid as the Teacher/s or staff member may judge to be reasonably necessary.

To be signed by Parent / Guardian
Parent / Guardian signature / Date
Signatures
Please refer to the Policies handbookfor Privacy Policy.
Parent/Guardian Commitment:
  • This application is a registration of interest in a place at Insight Education Centre. Insight Education Centre will contact the applicant to confirm placement.
  • Formal letters of offer are issued in writing (by email or post), and are conditional upon an interview and payment of the application and/or registration fee
  • Upon acceptance of the place, parents/guardians agree to follow the rules and policies of Insight Education Centre
  • Payment information for the application and/or registration fee (refer below) is enclosed
  • All necessary documents (refer below for checklist) are attached

To be signed by Parent / Guardian
Parent / Guardian signature / Date
Parent / Guardian signature / Date
Checklist of documents to be attached
/ Birth Certificate / / School Bus Services – Registration of Interest
/ Immunisation Documents / / Ophthalmologist / Optometrist report
/ Visa Information (if applicable) / / EVAC referral / assessment
/ Family Court Order details / / Medical plans
/ Past school reports including NAPLAN test
Payment information
Please indicate your method of payment below:
/ Cash
/ Cheque (payable to Insight Education Centre for the Blind & Vision Impaired)
/ EFT
Account Name: Insight Education Centre for the Blind & Vision Impaired (NAB)
BSB: 083 004
Account Number: 89 385 1725
/ Credit card (complete the following)
/ Bank card
/ Master card
/ Visa
Card number:
Expiry:
Verification number:
Card holder’s Name:
Signature:

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