PEAC Student Registration Form
Strictly Confidential
This information, that is required for each student participating in PEAC, will allow the supervising PEAC teachers to plan and provide for your child’s individual needs while he or she attends PEAC. It is not used for any other purpose.
Is this the first time you have completed this form? *
Required
Student Details
Student First Name *
Your answer
Student Surname *
Your answer
Date of Birth: *
MM
/
DD
/
YYYY
Gender *
School: *
Your answer
Year in 2019 *
Home Address: *
Your answer
Parent/Guardian Contact Details
Parent/Guardian Name: *
Primary contact for PEAC
Your answer
Parent/Guardian Phone Number (mobile) *
Your answer
Parent/Guardian Phone Number (home)
If applicable
Your answer
Parent/Guardian Phone Number (work)
If applicable
Your answer
Parent/Guardian Email Address: *
This will be used for PEAC communications use only.
Your answer
Additional Parent/Guardian Contact Details
Will be used if the primary contact cannot be reached
Additional Parent/Guardian Name:
Your answer
Additional Parent/Guardian Phone Number (mobile):
Your answer
Additional Parent/Guardian Phone Number (home)
Your answer
Additional Parent/Guardian Phone Number (work)
Your answer
Emergency Contact Details
Someone other than a parent/guardian
Emergency Contact Name: *
Your answer
Emergency Contact Phone Number: *
Your answer
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 any further details
Your answer
Tetanus vaccination date
If known, what was the date of your child's last tetanus vaccination?
MM
/
DD
/
YYYY
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
Your answer
Student Health Care Plan *
Does your child have a current Health Care Authorisation Plan at school?
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).
Your answer
Name of Medical Practice:
Your answer
Doctor's Name:
Your answer
Doctor's Phone Number:
Your answer
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:
Your answer
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. Student access is contingent on abiding by the 'PEAC Student Computer & Internet User Agreement'.
Internet Access Permission *
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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