Student Information - Child 1
Family Name:
Given Names:
Date of Birth:
Gender: MaleFemale
Address:
Country of Birth:
Ethnic Background:
Language(s) Spoken at Home:
Applying For:
Location: Georges Hall
Programs: Homeschool 3-Day ProgramQuran and ArabicAfter-School Tuition
Levels: KindyStage 1Stage 2Stage 3Stage 4Stage 5
Current School:
Current Grade:
Please list any special circumstances of which Atheera Education should be made aware. (e.g physical/intellectual/emotional/learning difficulties, behavioural challenges, anxiety, ADHD, autism, gifts/talents. Please provide appropriate reports/ assessments of such circumstances if applicable).
Student Information - Child 2
Family Name:
Given Names:
Date of Birth:
Gender: MaleFemale
Applying For:
Location: Georges Hall
Programs: Homeschool 3-Day ProgramQuran and ArabicAfter-School Tuition
Levels: KindyStage 1Stage 2Stage 3Stage 4Stage 5
Current School:
Current Grade:
Please list any special circumstances of which Atheera Education should be made aware. (e.g physical/intellectual/emotional/learning difficulties, behavioural challenges, anxiety, ADHD, autism, gifts/talents. Please provide appropriate reports/ assessments of such circumstances if applicable).
Student Information - Child 3
Family Name:
Given Names:
Date of Birth:
Gender: MaleFemale
Applying For:
Location: Georges Hall
Programs: Homeschool 3-Day ProgramQuran and ArabicAfter-School Tuition
Levels: KindyStage 1Stage 2Stage 3Stage 4Stage 5
Current School:
Current Grade:
Please list any special circumstances of which Atheera Education should be made aware. (e.g physical/intellectual/emotional/learning difficulties, behavioural challenges, anxiety, ADHD, autism, gifts/talents. Please provide appropriate reports/ assessments of such circumstances if applicable).
Student Information - Child 4
Family Name:
Given Names:
Date of Birth:
Gender: MaleFemale
Applying For:
Location: Georges Hall
Programs: Homeschool 3-Day ProgramQuran and ArabicAfter-School Tuition
Levels: KindyStage 1Stage 2Stage 3Stage 4Stage 5
Current School:
Current Grade:
Please list any special circumstances of which Atheera Education should be made aware. (e.g physical/intellectual/emotional/learning difficulties, behavioural challenges, anxiety, ADHD, autism, gifts/talents. Please provide appropriate reports/ assessments of such circumstances if applicable).
Social Media Permission
I give Atheera permission to use my child/ren’s photos on all our social media platforms
YesNo
With acknowledging and granting permission for Atheera to use your child/ren’s photo it will be on social media platforms, promotional material but not limited to these specifics mentioned.
Family Details
Child lives with:
Both ParentsMotherFatherGuardian
Are there any Custody restrictions?
NoYes ( Please attach appropriate documents )
Notes/Information about custody restrictions:
Parents / Guardian Details
Father Full Name:
Address:
Suburb:
Postcode:
Mobile:
Email:
Mother Full Name:
Address:
Suburb:
Postcode:
Mobile:
Email:
Student Medical Information:
Medical Card Number:
Ref No:
Name of Family Doctor:
Phone:
Asthma Action PlanAnaphylaxis Action Plan
Emergency Contact Details
Please nominate two people who may be contacted in the event of an emergency, when parents cannot be contacted. Ideally, the contact people should be those who live in close proximity to Atheera.
Emergency Contact 1
Contact Name:
Relationship To Child:
Mobile Phone:
Emergency Contact 2
Contact Name:
Relationship To Child:
Mobile Phone:
Billing Address Each Parent/guardian is responsible for all accounts
Title:
Family Name:
Address:
Suburb:
Postcode:
State:
Email:
Mobile:
Declaration & Statement of Commitment
To be completed and signed by both parents/guardians unless otherwise agreed to by Atheera in writing.
I/We certify that the above information given herein by me/us is correct.
I/We understand, have read and understood and agree to be bound by the Conditions of Enrolment (CoE)
I/We understand, have read and understood and agree to be bound by the Release Agreement
I/We agree to be jointly liable for payment of all fees, costs and charges as set out in the CoE.
I/We also undertake to assist my/our child in upholding the ethos of Atheera and agree to co-operate with Atheera’s management in supporting their rules and regulations.
Father’s Signature
Mother’s Signature
Date
Disclaimer: Whole Term Commitments are required. REFUNDS DO NOT APPLY (Refer to the Conditions of Enrolment (CoE) Agreement)
Total Price
$0
