Enrollment Form
Child's Information
Name
*
First Name
Last Name
Gender
*
Please Select
Male
Female
Religion
*
Cultural Background
*
Language/s spoken at home
*
Date of Birth
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Does your child attend another Centre: YES/NO! If Yes - Name of Service
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please select all preferred Enrolment day/s
*
Monday: 9am-2:30pm
Tuesday: 9am-2:30pm
Wednesday: 9am-2:30pm
Thursday: 9am-2:30pm
Friday: 9am-2:30pm
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Family Circumstances
Other Child/ren living at home? If YES, please provide details.
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Are there any custodial arrangements, or injunction orders relevant to this child? If YES, please provide details with any certified copy of any documents relating to this issue/s.
Medical Circumstances
Is your Child immunised?
*
Yes
No
Does your Child suffer from allergies? If Yes, please provide details with an action plan If required by your GP
*
Has your Child been at risk of Anaphylaxis? If Yes, please provide details with an action plan if required by your GP. You will need to provide an Auto-injector (Epi-Pen) and renew prior to its expiry date ends
*
Does your Child suffer from Asthma? If Yes, please provide details with an action plan if required by your GP
*
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Parental Information
Name:
*
First Name
Last Name
Date of birth:
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Country of birth:
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email Address
*
Cultural background:
*
Religion:
*
Language/s spoken at home
*
Relationship to child:
*
Marital Status
*
Please Select
Single
Married
Defacto
Separated
Divorced
Widowed
Occupation
*
Place of Employment
*
Parent/Guardian 2
Name:
*
First Name
Last Name
Date of birth:
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Country of birth:
*
Address (if not the same as above)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email Address
*
Cultural background
*
Religion:
*
Language/s spoken at home:
*
Relationship to Child:
*
Marital Status
*
Please Select
Single
Married
Defacto
Separated
Divorced
Widowed
Occupation
*
Place of Employment
*
Mobile Number
*
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Contact In case of Emergency
If your Child is unwell, or there is an emergency, parents are our first line of contact. In the event that parents cannot be reached, two emergency contacts must be provided who will have the authority to collect your child from iLearn Tuition Center in your absence. They will be contacted if you are not reachable in the event of an emergency. Your Child will not be permitted to leave with anyone who does not have written consent from you (with exception of verbal consent in an emergency). Anyone unknown to Educators who arrives to collect your child will be asked for Identification (ID).
Name
*
First Name
Last Name
Date of Birth
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Mobile Number
*
Relationship to Child
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please TICK:
*
I give authorisation for this person to be contacted if my child is unwell or in any case of an emergency
I give authorisation for this person to be informed of the accident, injury, trauma or illness.
I give authorisation for this person to drop-off and pick up my child from iLearn tuition Centre (unless otherwise specified)
Parent name:
*
First Name
Last Name
Signature:
*
Date Signed:
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
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Emergency Contact 2
Name
*
First Name
Last Name
Date of birth
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Relationship to child:
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
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Please TICK:
*
I give authorisation for this person to be contacted if my child is unwell or in any case of an emergency
I give authorisation for this person to be informed of the accident, injury, trauma or illness.
I give authorisation for this person to drop-off and pick up my child from iLearn tuition Centre (unless otherwise specified)
Name
*
First Name
Last Name
Signature
*
Date signed:
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
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Diagnosis
Has your child be diagnosed with any type of special need? If Yes, please provide details with a certified copy of any document's relating to the issue/s
*
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Concerns
Do you have any specific concerns about your child's academic development? If Yes, please provide details.
*
Goals
Do you have any specific goals you would like your child to develop through tuition? If Yes, please provide details.
*
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