Student Information Form

Student Details

Student First Name*

Student Preferred Name

Student Last Name*

Date of Birth*

Gender*

School*

Nearest PEAC Centre

Year in 2019*

Identification Tool

Test Score VR

Test Score MR

Test Score TP

Status

Home Address*

Parent/Guardian Contact Details

Parent/Guardian Name*

Primary contact for PEAC

Parent/Guardian Phone Number (mobile)*

Parent/Guardian Phone Number (home)

Parent/Guardian Phone Number (work)

Parent/Guardian Email Address*

This will be used for PEAC communications only.

Additional Parent/Guardian Contact Details

Will be used if the primary contact cannot be reached

Additional Parent/Guardian Name

Additional Parent/Guardian Phone Number (mobile)

Additional Parent/Guardian Phone Number (home)

Additional Parent/Guardian Phone Number (work)

Emergency Contact Details

Someone other than a parent/guardian

Emergency Contact Name*

Emergency Contact Phone Number*

Student Medical Details

Medical Conditions*

Is your child subject to seizures, fainting, epilepsy, diabetes or any other condition that may affect his or her safety?

Medical Condition Details

If yes to the above question, please provide further details

Tetanus Vaccination Date

If known, what was the date of your child's last tetanus vaccination?

Severe Allergies*

Is your child severely allergic to anything such as penicillin, other drugs, foods, bites etc.?

Allergy Details

If yes to the above question, please provide further details

Student Health Care Plan*

Does your child have a current Health Care Authorisation Plan at school?

Upload Student Health Care Plan

Please scan and upload the student's up to date Health Care Plan here, or if not currently available , email to North Metro PEAC

Other Conditions or Needs

If applicable, please provide any other relevant information about your child, that will enable us to provide better care for your child (inc. social and emotional needs).

Name of Medical Practice:

Doctor's Name:

Doctor's Phone Number:

Medication Prescribed*

Is your child presently taking tablets and/or other forms of perscribed medication? (Parents/guardians are requested to make arrangements with the teacher-in-charge for the safekeeping and handling of medications).

Medication Details

If yes to the above question, please state name of medication, dosage and frequency of use:

Medication Self-Administration

Does your child self-administer the medication?

Media Consent

Student's images and/or their work samples are often published to recognise excellence or effort and may appear in local newspapers, on the internet, in newsletters or on film or video. Their names may also be included however contact details are not. We request your permission to use images and/or work samples of your child in the ways listed below. You are of course at liberty to withdraw your consent at any time by contacting PEAC administration or completing this form again.

* PEAC website or any medium in relation to PEAC related activities.
* Promotional material for the Department of Education or PEAC.
* Educational articles for local and community newspapers.

Media Consent*

Internet Access Permission

Student access to the internet is provided in accordance with school policy. Student access is contingent on abiding by the 'PEAC Student Computer & Internet User Agreement'.

Internet Access Permission*

Travel Agreements

I am responsible for the safe and legal transport of my child to and from PEAC courses. There must be a handover of responsibility for the child between the transport provider and the PEAC teacher. Students are to arrive no earlier than 10 minutes prior to the commencement of the course session and are to be collected no later than 10 minutes after the session has been completed.

Travel Agreements*

ECU Induction Parent Consent - Year 4 2019 only

Please complete the sections below if your child is attending Induction at ECU in 2019.

Is your newly identified Year 4 PEAC student attending the ECU Induction?

Year 4 2019 Induction Consent

Agreement to the following conditions is required for participation in this event.

Consent*

I consent to my child participating in the PEAC Year 4 Induction Day at Edith Cowan University, Joondalup Campus in Term 4 Week 9, 2019

Transport*

I am responsible for providing safe and legal transport for my child to and from the venue. No unaccompanied transport is permitted to and from the venue.

Student Handover*

I confirm that my child will be delivered by the transport provider to the teacher at the venue and collected from the teacher at the conclusion of the event.

Medical Treatment*

I give permission for my child to receive medical treatment in case of an emergency.

If the proposed event poses any additional health risks, to those identified in the Student Information Form completed above, please outline below.

Example of additional health risk; if your child suffers from anaphylaxis please consider the storage of an adrenaline auto injector at the appropriate temperature, or timing of meals for students with Type 1 diabetes.

Liability*

I am aware that the school and its employees are not responsible for personal injuries or property damage, which may occur at an external venue, unless the school or its employees are proven negligent.

Payment*

I am aware the $45 payment for this event is due in March 2020. A reminder email will be sent with Round 1 course enrolment.

Name of Best Contact on the day of the Induction*

Phone Number of Best Contact on the day of the Induction*

Relationship to Child of Best Contact on the day of the Induction*

ECU Day Allocated

ECU Colour Group