Student Information Form

Student Details

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Student ID

Student First Name*

Student Preferred Name

Student Last Name*

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Student Full Name

Date of Birth*

Gender*

Does the student identify as Aboriginal or Torres Strait Islander?*

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School Code

School*

Year in 2022*

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Identification Tool

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Test Score VR

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Test Score MR

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Test Score TP

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Status

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Round 1 Course

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Which preference did they get R1?

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Round 2 Course

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Which preference did they get R2?

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Round 3 Course

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Which preference did they get R3?

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Notes on preference changes

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Parent Email (App)

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)

Additional Parent/Guardian Email Address

This will be used for PEAC communications only.

Emergency Contact Details

Someone other than a parent/guardian

Emergency Contact Name 1*

Emergency Contact Phone Number 1*

Emergency Contact Name 2*

Emergency Contact Phone Number 2*

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

Disability*

Does your child have a disability?

Disability 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

Max. file size: 128 MB.

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 for use of technology in PEAC courses. Student access is contingent on abiding by the 'PEAC Student Computer & Internet User Agreement' below.

PEAC Student Computer & Internet User Agreement*

Student Computer and Internet User Agreement

I agree to follow the PEAC online rules set out below when I use the computer, internet or a log-on account for PEAC work at a PEAC Centre or at home.

Communicating with Clarity and Precision while Taking Responsible Risks

* I will ask the teacher before accessing PEAC computers
* It is my responsibility to inform the teacher immediately if I encounter any problem

Managing Impulsivity

* I will keep a record of my login details (username and password) and not share them with others
* I will not give out my name, phone number, address, name of the school, photographs or other details about myself or others without checking with the teacher first
* I will take care when using the computer equipment and will not change any computer settings or access other students’ folders
* I will not use the computers to be mean, rude or unkind to other people

Thinking about your Thinking

* If I download work or pictures from the Internet I will acknowledge where it came from
* I know that I am responsible for my own online behaviour
* I know that PEAC and the Department of Education is able to see anything I access online or email
* I know that I am responsible for any thumb drives or devices that are used in class

I understand that

* The misuse of online services will result in consequences and communication to my parents and home-school

I agree to abide by the acceptable usage agreement for PEAC students.

I understand that if I break any of the rules in the agreement; it may result in disciplinary action determined by PEAC teachers.

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*

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ECU Induction Parent Consent - Year 4 2021 only

Please complete the sections below if your child is attending Induction at ECU in 2021.

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

Year 4 2021 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, 2021

Relationship to student of person giving consent*

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.

Special Considerations: 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 on an excursion, unless the school or its employees are proven negligent.

Payment*

I am aware the $45 payment for this event is is to be made when booking your Induction Day.

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*

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ECU Day Booked

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ECU Colour Group

Student Details

Parent/Guardian Contact Details

Additional Parent/Guardian Contact Details

Emergency Contact Details

Student Medical Details

Media Consent

Internet Access Permission

Travel Agreements

ECU Induction Parent Consent - Year 4 2021 only

Year 4 2021 Induction Consent

Yuluma PEAC (Admin Centre)

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