15 Harbour Street Wollongong NSW 2500 Phone: 4228 6011 Fax: 4229 8555 ABN 70 309 539 954 Temporary CRICOS PROVIDER NO 01369C CEC www.stmary.nsw.edu.au
INTERNATIONAL STUDENT APPLICATION FOR ENROLMENT PROPOSED STARTING CALENDAR YEAR _____________________ eg 2012
PROPOSED STARTING YEAR LEVEL ____________________________ eg Year 7
PROPOSED STARTING TERM ______________________ eg Term 2
STUDENT DETAILS Family Name:
Date of Birth:
Religion:
Given Name: Preferred First Name: Address: No. and Street Name: Suburb: Postcode: Home Ph: Passport Number: Nationality:
Country of birth:
PREVIOUS SCHOOLS Name of school
Grade(s)
I / We give permission for school to contact previous schools
Years of attendance Yes
No
LEVEL OF ENGLISH LANGUAGE ACHIEVEMENT Is English your first language? Yes No my first language is AEAS Score IELTS Score (Australian Education Assessment services) (International English Language Testing System) Students are expected to have a high level of proficiency in English and to have had a basic familiarity with the language for at least the last two years. The cost of extra tuition, should this be necessary, is the responsibility of the parent/guardian. Depending on the student’s English ability, she may be required to successfully complete an ELICOS course.
INTERESTS In which of the following co-‐curricular activities has the student participated? Music-‐vocal Instrumental (indicate instrument) Sport Art
GUARDIANSHIP St Mary’s does not have a policy which supports a Home Stay program nor undertakes guardianship of prospective overseas students. A parent, or relative approved by the Department of Immigration and Citizenship (DIAC), must take responsibility for the guardianship and welfare of the student. MOTHER Title: (eg Mrs/Ms/Dr)
Surname:
Given Name:
Address: (leave blank if same as student address_________________________________________________ __________________________________________________________________________________________
Home Ph: Mob:
Business Ph: Email:
Occupation: Employer: Religion:
Nationality:
Country of Birth: FATHER Title: (eg Mr/Dr)
Surname:
Given Name:
Address: (leave blank if same as student address) _________________________________________________ __________________________________________________________________________________________
Home Ph: Mob:
Business Ph: Email:
Occupation: Employer: Religion: Country of Birth:
Nationality:
GUARDIAN IN AUSTRALIA Title: (eg Mrs/Ms/Dr)
Surname:
Given Name:
Guardian’s permanent address in Australia: ______________________________________________ __________________________________________________________________________________ Home Ph: Business Ph: Mob: Email: Relationship to student: Occupation:
Employer:
Religion:
Nationality:
Country of Birth:
Date of Birth:
Approval from DIAC:
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EMERGENCY CONTACT INFORMATION IN AUSTRALIA (to be used in the event of an emergency if parents/guardian cannot be contacted, i.e local contact in Australia)
Contact 1
Contact 2
Name:
Name:
Relationship to student:
Relationship to student:
Ph: Mobile
Ph: Mobile:
FAMILY MAILING DETAILS
FAMILY BILLING DETAILS
All School correspondence and reports to be sent to:
College Fee accounts to be sent to:
Full Name:
Relationship to student:
Relationship to student:
Address:
Address:
Home Ph Business Ph:
Mobile:
Email:
Full Name:
Home Ph Business Ph:
Mobile:
Email:
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MEDICAL INFORMATION Doctor’s Name: No. and Street Name: Suburb: Postcode: Phone: Medicare No. (if applicable) Private Health Fund: Private Health Fund No: Medical Conditions: Please specify any medical conditions the student suffers from, eg asthma, diabetes and/or any prescribed medication taken by the student. ______________________________________________________________________________________ ______________________________________________________________________________________ Allergies: Please list any known allergies the student has, eg allergy to nuts, penicillin, bee stings including specific details. _______________________________________________________________________________________ Has the student been diagnosed as being at risk of anaphylaxis? Yes No If yes, does the student have an EpiPen? Yes No
IMMUNISATION: Please indicate if the student has been immunized against the following: Chickenpox Diphtheria-‐Tetanus-‐Whooping Cough Haemophilus Influenza type b (Hib) Hepatitis B Human Papillomavirus (HPV) (12-‐18yrs) Measles-‐Mumps-‐Rubella Meningococcal C disease Pneumococcal disease Polio Rotavirus
Please circle Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No
Date of immunization _ _ / _ _ / _ _ _ _ _ _ / _ _ / _ _ _ _ _ _ / _ _ / _ _ _ _ _ _ / _ _ / _ _ _ _ _ _ / _ _ / _ _ _ _ _ _ / _ _ / _ _ _ _ _ _ / _ _ / _ _ _ _ _ _ / _ _ / _ _ _ _ _ _ / _ _ / _ _ _ _ _ _ / _ _ / _ _ _ _
HEALTH AND SAFETY To your knowledge, is there anything in your child’s history or circumstances (including medical history) which might pose a risk of any type to her, other students, or staff at this school? Yes No If yes, please provide a brief description. ___________________________________________________________________________________ Please provide names and contact details of health professionals or other relevant agencies that have knowledge of these issues. ___________________________________________________________________________________ Does your child have any history of violent behaviour? Yes No Does your child have any history of behavioural problems (including verbal bullying)? Yes No Has your child ever been suspended or expelled from any previous school? Yes No If yes, was this for • Actual violence to any person? Yes No • Possession of a weapon or any item used to cause an injury? Yes No • Intimidation, bullying or harassment of students or staff at a school? Yes No • Threats of violence? Yes No • Illegal drugs? Yes No • Other (please specify) __________________________________________________________ I / We will provide written consent to the school on request to contact health professionals or other relevant agencies Yes No 4
DECLARATION BY PARENTS/GUARDIANS I understand St Mary Star of the Sea College is bound by the privacy laws operative in NSW and will hold all information in confidence. However, personal information supplied in this application may be provided to any official authority or organization deemed appropriate by the Principal. I/We, the undersigned apply to have the above-‐mentioned student entered at St Mary Star of the Sea College and agree, should the application be accepted to comply with the ‘Formalisation of Enrolment Document’. We agree to abide by these conditions and any regulations in force at the College and to pay all fees and monies as they fall due to the College I declare that the information I have given in this form is true and correct. I/we understand that if any misleading information has been provided, or any omission of significant, relevant information made in this application for enrolment, acceptance will not be granted, or if discovered after acceptance the enrolment may be withdrawn. This application requires the signatures of both parents. If both signatures are not appended, the circumstances should be indicated in writing. SIGNATURE OF PARENTS OR GUARDIANS 1
DATE:
2
DATE:
TO ACCOMPANY THIS APPLICATION
A non refundable application fee of $A 100.00 A certified copy of birth certificate or other evidence of date of birth Proof of English proficiency level (test certificate for AEAS, IELTS) Copies of student’s two most recent reports (translated and certified if not in English) Copies of any public examination results A letter of recommendation from the Principal of the student’s present school, if readily available
Copy of a recent reference Relevant medical, Immunisation Certificates and special needs information (if applicable)
Certified copies of passport, visa documentation
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