1: LH APPLIC. ENROLMENT

APPLICATION FOR ENROLMENT
Entitlement to Enrolment

Chinchilla Student Accommodation Association Inc. (CSAA), trades as Leichhardt House Student Hostel (the Hostel). Both CSAA and the Hostel staff are committed to providing isolated students from the Western Downs region of Queensland with a quality weekly boarding service. A prospective boarder applying for a place at the Hostel must be enrolled, '... if they are entitled to enrolment'. There are, however, a number of factors that can affect a prospective boarders entitlement to enrolment, please see Leichhardt House Boarding Handbook for details.
Personal Information

CSAA, as the governing body of the Hostel, needs to ask for personal information from prospective boarders and parents/carers so it can plan, provide and report on its operations and monitor service compliance under relevant legislation and guidelines. Please take the time to read Section 2 'Management of Personal and Confidential Information' of the Leichhardt House: 'Code of Conduct' which outlines in greater detail the nature of the use and disclosure of the information that you provide.
Instructions

Failure or refusal to complete the sections of the form marked with an (*) or to provide required documentation, if required, will result in the application not being completed, submitted or processed. Sections of the form not marked (*) are optional; however, failure to complete these sections may result in the Hostel not being eligible for important Commonwealth Government/Queensland Government funding that is reliant on such information.
Section 1: PROSPECTIVE BOARDER DETAILS
Name*

SurnameGiven Name (1st Name)Middle Name
Preferred Name
Date of Birth*

DayMonthYear
Gender*

FemaleMale
Is the prospective boarder of Aboriginal or Torres Strait Islander origin?

NOAboriginalTorres Strait IslanderAboriginal & Torres Strait Islander
Current Year Level
Current School
Proposed Year of entry to Hostel*
Proposed Year Level upon entry to Hostel*
Residential Address*

Property Name (If applicable)

Street Address

Town/SuburbState/Postcode
Postal Address*

Property Name/MS/PO Box

Street Address

Town/SuburbState/Postcode
Prospective mode of transport to school/Hostel?

Private Vehicle (Hostel opens at 8:00 am on Monday/first day of the school week)School Bus
Prospective mode of transport from school to home?

Private Vehicle (Pick up at school at 3:00 pm on Friday/last day of the school week)School Bus (Departs school at at 3:00 pm on Friday/last day of the school week)
Does prospective boarder have any siblings who have boarded at the Hostel in the past? (Please provide details)
Does prospective boarder have any siblings who intend to board at the Hostel in the future? (Please provide details)
Section 2: PARENT/CARER DETAILS
Parent Carer 1*

First NameLast Name
Relationship to prospective boarder
Status*

Responsible for Parenting?Lives with Prospective Boarder?Contact in Emergency?
Home Phone
Please enter a valid phone number.Format: (07) 0000 0000.
Mobile Phone*
Please enter a valid phone number.Format: 0000 000 000.
Parent/carer 1 email*
example@example.com
Residential Address*

Same as Prospective BoarderDifferent Address (Add below)
Residential Address

Property Name (If applicable)

Street Address

Town/SuburbState/Postcode
Postal Address*

Same as Prospective BoarderDifferent Address (Add below)
Postal Address

Property Name/MS/PO Box

Street Address

Town/SuburbState/Postcode
Parent Carer 2

First NameLast Name
Relationship to prospective boarder
Status

Responsible for Parenting?Lives with Prospective Boarder?Contact in Emergency?
Home Phone
Please enter a valid phone number.Format: (07) 0000 0000.
Mobile Phone
Please enter a valid phone number.Format: 0000 000 000.
Parent/carer 2 email
example@example.com
Residential Address*

Same as Prospective BoarderSame as Parent/Carer 1Different Address (Add below)
Residential Address

Property Name (If applicable)

Street Address

Town/SuburbState/Postcode
Postal Address

Same as Prospective BoarderSame as Parent/Carer 1Different Address (Add below)
Postal Address

Property Name/MS/PO Box

Street Address

Town/SuburbState/Postcode
Section 3: SPECIAL FAMILY CIRCUMSTANCES
Are there any current court orders re: the Family Law Act 1975 concerning the welfare, safety or parenting arrangements of the prospective boarder?*

Parenting PlanConsent OrderParenting OrderNONEUnknown
Are there any other current court orders/domestic violence orders, concerning the welfare, safety or parenting arrangements of the prospective boarder?*

NOYES
Do any access restrictions apply to the prospective boarder?*

NOYES
Section 4: BOARDING FEES/FUNDING
Is the prospective boarder an Australian citizen/permanent resident?

NO (Please contact Hostel staff before submitting an application)YES
Are the prospective boarder’s parents’/guardians’ permanent residents of Queensland?

NO (Please contact Hostel staff before submitting an application)YES
Will the prospective boarder qualify for Centrelink Assistance for Isolated Children?

NO (Please contact Hostel staff before submitting an application)YESUNSURE
Section 5: EMERGENCY CONTACTS

For an emergency where the parent/carer cannot be contacted. Please ensure that the people named have agreed to be an emergency contact person and have allowed their details to be provided to the Hostel.
EMERGENCY CONTACT 1*

First NameLast Name
Relationship to prospective boarder
Home Phone
Please enter a valid phone number.Format: (07) 0000 0000.
Mobile Phone*
Please enter a valid phone number.Format: 0000 000 000.
Residential Address

Property Name (If applicable)

Street Address

Town/SuburbState/Postcode
EMERGENCY CONTACT 2*

First NameLast Name
Relationship to prospective boarder
Home Phone
Please enter a valid phone number.Format: (07) 0000 0000.
Mobile Phone*
Please enter a valid phone number.Format: 0000 000 000.
Residential Address

Property Name (If applicable)

Street Address

Town/SuburbState/Postcode
Section 6: PROSPECTIVE BOARDER MEDICAL DETAILS
Personal medical information

CSAA is collecting this medical information in order to address the medical needs of your child during her/his time in residence as a boarder at the Hostel, or when taking part in activities outside the Hostel, whilst the Hostel has a 'duty of care'. It is the responsibility of parents/carers to notify the Hostel, in writing, of any changes to a boarders medical conditions/ information. Please remember that incomplete or inaccurate health information may put your child’s health at risk.
Confidentiality

Your medical information will be used by Hostel staff in the event that your child (during her/his time in residence as a boarder at the Hostel, or when taking part in activities outside the Hostel, whilst the Hostel has a 'duty of care'), requires medical attention. Mandatory (e.g. Medicare number) and relevant (e.g. existing medical condition) information only, will be disclosed to Queensland Health staff on a need-to-know basis and only when required to meet the immediate medical needs of your child. It is essential that the Hostel is advised of any existing medical conditions before the prospective boarders' first day of boarding.
Does prospective boarder suffer from any SIGNIFICANT HEALTH ISSUES/MEDICAL ALERTS (e.g. diabetes; epilepsy; heart condition; asthma etc.) OR any SEVERE ALLERGIES/ANAPHYLAXIS (e.g. nuts, seafood, dairy, insect bites etc.) that Hostel staff need to be aware of*

NOYES (Please outline details below and provide Hostel staff with a copy of relevant management plan [e.g. Asthma Action Plan/ASCIA Anaphylaxis Action Plan]) before commencement of boarding.
SIGNIFICANT HEALTH ISSUES/MEDICAL ALERTS/SEVERE ALLERGIES/ ANAPHYLAXIS
Does the prospective boarder suffer from any ONGOING MEDICAL CONDITIONS/ISSUES that the Hostel staff need to be aware of?*

NOYES (Please outline details below and provide Hostel staff with a copy of relevant management plan) before commencement of boarding.
ONGOING MEDICAL CONDITIONS/ISSUES
Will the prospective boarder require the regular administration of medication by Hostel staff?*

NOYES (Please complete Authorisation to Administer Medication)
Does the prospective boarder require any medical aids or devices (such as glasses, contact lenses, prosthetics or orthotics)?

NOYES (Please add details below)
MEDICAL AIDS/DEVICES
Medicare Card number (9 digits) issue number (1 digit) and IRN [number beside the prospective boarders name] (1 digit) & Expiry Date:
Health Care Card number:
Health fund name and member number (if applicable):
Doctors name & phone number:
Personal information and privacy statement
Chinchilla Student Accommodation Association Inc. (CSAA) is collecting the information on this form for the purposes of:
1. Assessing whether your application for enrolment should be approved;
2. Assisting Hostel staff to plan and maintain the good order and management of the Hostel, and to fulfil their ‘duty of care’ to all boarders;
3. Optimize communication between Hostel staff and parents/carers’;
4. Where required, meeting reporting obligations required under Commonwealth Government and Queensland State Government funding arrangements;
5. Personal Information from this form must be supplied to Centrelink, if requested, in compliance with sections 194 and 195 of the Social Security (Administration) Act 1999;
6. Personal information collected on this form may, where requested, also be disclosed to [authorised] third parties or as required by law.
Your information will be stored securely and is only accessible by the Hostel Managers.

Please take the time to read Section 2 'Management of Personal and Confidential Information' of the Leichhardt House: 'Code of Conduct' which outlines in greater detail the nature of the use and disclosure of the information that you provide.

If you wish to access or correct any of the personal information on this form or discuss how it has been dealt with, please contact the Hostel staff in the first instance. If you have a concern or complaint about the way your personal information has been collected, used, stored or disclosed, please also contact the Hostel in the first instance.
Application to enrol

We/I hereby apply to enrol our/my child at Leichhardt House Student Hostel. We/I understand that supplying false or incorrect information on this form may lead to the reversal of a decision to approve enrolment. We/I believe that the information we/I have supplied on this form is true and correct in every particular, to the best of my knowledge.
Prospective Boarder Name*

First NameLast Name
Prospective Boarder Signature*
Parent/Carer Name*

First NameLast Name
Parent/Carer Signature*
Date*

DayMonthYear
Date
Hour MinutesAM/PM Option
Should be Empty:

APPLICATION FOR ENROLMENT

Entitlement to Enrolment

Personal Information

Instructions

Section 1: PROSPECTIVE BOARDER DETAILS

Section 2: PARENT/CARER DETAILS

Section 3: SPECIAL FAMILY CIRCUMSTANCES

Section 4: BOARDING FEES/FUNDING

Section 5: EMERGENCY CONTACTS

Section 6: PROSPECTIVE BOARDER MEDICAL DETAILS

Personal medical information

Confidentiality

Personal information and privacy statement

Application to enrol