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$TUBENT ENROLMENT INFORMATIO}"I

TZeaee prrsvide a eapy at

*tudent

bzrtfu

- 2O

c**if rcatelu pa\spart when *ubrnitting the enralr.nent; t*rrm t* tfu* &eneral Affitce

FERSONAL DETA,LS OT STUUEI'IT

H

$urname:

C,foRG

Second $iqen Narne:

preferred Name (if appticabte):
.9*v

&tu

d e

r+"i+k'i. rdnlral*

nt

7'll

ob\l

*

7'&

R

Rapylh€ L

F*stGiven tlarne:.

.i"

Tztte:tMis*M*Mr) M

eru N ESsY

urnb

E
Rn p fl
a7emal*

Bt*h bat*: tdd-mnt-y yy y

o43Z

er:

il tOtvtZooL
..--.-..-t-

1

277 8q 3

*zbtZng* attendtmgTA

71ea5* |ill in.?rirnary lamily & At+,etnat"ive lamily detail* \/rhe& ther* i* *hare.d cael.*dy
detatls

Trtrn

The student lives with the
Fannilv A:
?,Xo.

tti*k

ane't

& 9treet: ar P0 Eax

det"ails

suburb:
state:

{xr,*yu

J

3Z

Co\^NcrL
ll ru-

C,LtfTON

D Salanaed U

Maslly

ST

V[ L

?astcode:

3D68

Silentfiumber:

Te1*p'*aree ?"duffih*r

04l I 33 L7 8'z
Address, kq iha r, ne
bro ckrna.-

wabiteNurnbe',
Emair

Accasianally D Never

F

(tick)

DYes

il

No

ax ?,|urnb*r:

G q rn ai L, C o ryr

*rqt"*6" usz" *NLv
*?tsld'rs Narne and &trth *a,"e fr{*a{ $itLkt*d (t ck}

Year
tr*e."tel

il

fS Ye*

h,30

*.nra2rn*ztt" bate:

Tnnetatsling C"ntered
in Ytrs'{. *lass

L4ause

%,tuderl| fr"matl lt eLdr*ss:

il Complete

trnrnunisa rell *erttlicar.e reeeivetJ? . (.lt{:?,)
Xs

trN0

th*re a Merlieatr h\*rLtar the student? ilick)

*rs** lh* btudent *av* a Azsaflilitv

l*

Wurnbar?

ll.ickt

fras lhe dqr;um*ntation
?4ave l?v: crsn<lition*

?saen pravrd*rJ

b*en

tr-a*l u*ditt *r3: 7 *b 2*1 6

met"

tr Yes

IJ Na

and r*lained an

ta camplete

I n Not sigtiteo

sc?usrsl

r*cards?

*i*ability lU 7"&o".
1*;

Vac

*Ye*

lk* *nralm*nt?

naae

1

:T1 trt^

tJ

?4a

versianTe NOZ

PR'MAMV tr &$&ILY DET &r,L&
NATE: The '?RlbfiP'.ftY' Family is: "the family ar parent the sr.udeni ma*\ly liw*s with" . Additianal and klternative family farrns are
available from the sch*al if tkts is required. These additio*al fqrms are. d*signed ta cater far varying famlly cireum*lances.

p."ryaLT

k

UHT&tLfi {,pwtr*e?V **,fi"Z\}:

*ax{li*.k):
Tit|e: lft*,Mrs,

D
Mr,

Male

Dretc)

M

hmwLT & **TktL%:

{female

9*x

eOC Kfnn{ \\
g
K A: HA R t t\

Firstuame;

Yt!1\t: !?Yl1
wha

as

1"?

*"YY1l'1?7

A.duu A's ernptoyer? IYIE

ln v{ktck *ountry wa* kdult

d &.uatralza

Lesatewrnan'rl:

itO

r,t p

N.f

Sf fnpf

dwno

Adwu. B's ernpzoy er?

as

ln wktc,k cauntry

fl

fr A*e*r

i4 \i
BtR

l,tlt LB. ChAfn

was Adult B barn?

{Australia

ei Other tplease sp*city):

*th*r

WtUUt rf

.wh:11:ld"*7':?:?YYI]'::? {!ta-5 t c

k barn?

4. Uaes &,rlwlt" &, *Baak a language

TerusaNe

H 6ruN f.SS-I

t-egaxFirst?"trarne:

M us 1c tA N

A

qtc) /l/l R

-{itle: (Ms,?{trs,Mr,Dr

S

L*sat$urrzar**: B
t-esat

d frqab

ttiek).

O KC

f6

51

(please speeify}:

.t

Englz*h at

fu*r**? I,lt mqre lnan one langtsage ts *pc:k*a. al neme, trtdirare
tne o,ne tnal,* *pak*n rna*l *ften ) tti*k)
v.la, engfi*h anly
Yea l.Ssl*a*e sp*cityj:

Ooes &.dult B speak a Zanguage other than Engli*7t at
harn*? (lt ffiore than one language is spoken atharne. indicat*
the ore that is spoken most often.) (tickJ
No, English only
{
Yes (please specify):

72eas* rndteate any addztz*nal
lartguage* spaken b'g A,dult &":

Please indicate ax*g additianal
languages spoken by Adult B:

t?zarz

d
ru

lsanint*rpreterreqwired?ltick)

AYes

g

n

&o

ls art interpreter required?

(ttck)

A

Yes

ffi,,

fuigh**t year *t Xsrtrrrarrs *r **eem<1ary *ehaol
r:*mstlet*d? i.r"trk rnei (f r:r S:r:r:;rstts vtho have never
atlended t;chot:tl. tnark Y*ar I r:r *rquitak:nl or tsr.:ks',t't'.)

i* tke htqhe*t^ year at prirn'*ry ar *eeand.ary *r,h*a1t
&,dult ffi ha* eompleted"l li"ir:k an*) ii:t::t per:;i:rit; fifla )]a fi ,eter

t

tJ Y*ar

?.'V,lkar. z* t.ke

&dult lt,

**t&lhat.

?sa*

ettefided schaoi. mark'Ye ar

Yeer 1/ ot eq;J*Ja,?i1

A Y ear 11 *r

J

equfualer.,l

l) Y*:ar 1* rsr *r:4uiva1*.rtl
l)'{ear * r-* t:qui,talc:nl ar ?s*lav't
.?What is th* lev*tr at the ltighest <4ualitie,attan the f+dutrt

*r:ryplet*d?

*":

k

de{Jrce

hae

C

nar^t;hzot

qLratiacaliar.

persan has rtrsutbeen rt fsaia wor?..k:r lhe ia*I

fian*, e^1*, '\.

'io Tlwr:'e qwe*lirsn* ar* a*ked a* a requk*menl

l.-;es:t

C*rlitirat"e I t*

1V r;nc,ludtng

-'* r:k rs a1 q u aliti

trade r*rt)ficat*'i

cati a n

*What i* the aaewysati*n gr*rsp *t

*

fz..dult W? ?lear* selecl
**ctl2e|t*n gr*u;; iroff' ?"ie a1;lacn*{i li,l.. "il*
1t lhe per**n i* nrst turr*ni.l'l ir', ysairl aarr, r;;i na* ?i*d i; jr:'* ir'

the lesr, 12 m*n,n*, or nat, re|ircd in thrr 1etl. 12 r,:,ar',th*, please
Jse lnE:ir iast accupa?"iari 2, fielecl {,;r.sr, the at;ternad accupat"iart
gr*ap li*t.

12 re
A4

aN

r",

H tua*

a

li t;he perstsn lta-";

rt:l b*en ir', rsari w*rk l'*r

fianl.r5t(.,,(.tN

t1t* Cazu':n*nvr*;e1tln

**v*rnrnenl.

h11

^

t?,e lar:i

12 ,;
16

*chaal* acr*s* h,uatralia are r*qu*ed

r"a

sarne tnfarmatian

t*atnZanguag* *poken
&,re

TJ

tt

h*ult

*r abav*

l+dvanc*d riiplarrw I *ipiama

i

the

r,tiek o*e';

afrproprtat"e parenlal

iri pairJ wark but ha6 had a jah irs
the iatt '12 rrnrl"h*, *r 7a* retir*d in lne hs, 12 nt*t:\hs, please
u*e treir 1asi. *ceuSsatian l* -*,eleclfrrsrr, i?t* a'ttrllhe{t *ccupat.i*n
;Yr:tiS: li*i.

crslk:r:1 1?rc

*qtsival*tsl

13

Q?4 rs r

q lt llie pettoil i* nal c..rrrcr1tiy

1l l^nq

rsr

11 &acfs,:ktr rJr:Ere*

at abaue

.'?Whali% the aeeupatian graup ut &,dult lt"? ?le*se**lectlhe
aperaptia'Le parert"al aecu?etian gr*up trrsm lhe attrae\,ed iitil.

*

Y*ar 11

*ornpleted?

3 ltdvanr*t1 disslrsrna I Dipksrna
l) C*rttfi.cel*: I lrs lV lincludinE lrarl* r*rlilirale)
r,la

or *qulvalertt ar lselou'.)

YYear l{ 1-t1 gs3,y.iyztq1 "',
llY*ar * *r *euival*nt ar bal*w
/, Wkat i* tfue le'tal r:t the higlt*st qua\itir:ati*n

i1ick one)

wlor

Q

1?. rsr r,:qutvaler*

at?tame:

f.N

4 Ll5

fr

Pr*t*rredtangwageaf

yau znL*r**r"*d am being t*valved in *cfu**l Eraup

tgsr|*lr*rL:

f

r:Ls

2fr1$

A
naus

2.

Adult"

fr,

U

notices: f N( LIS i

*dull7 *B*th

n

I

Neither

versianTC NAZ

PR'WARV FAMILV CANTACT AETAII-S
Ad

u

lt

A

C

ontact. Ueu"aila:

Business t'{surs:
Can we

eantact AdultA, eiwork?

ttick) il Yes *{o

during
J,,
(rick) {t* e h mt5 a Y"t

ls Adult A usually home

businesshours?

il

ltlo

qbzb ll z b

wark-{atep?e*n*tla:
&th*r W*rk e*nta$t.
ir*rtrrnatiarz:

&,{t*r i"f*wrs:
as &^dwZt,&

usuaily harne

businesskaur*? (lick)

A.FTER druu fr ?\o

Hetrner*zephoneNu 0 |t-l
&tfuer

&tt*r

\ bZ b7

1Z

?4aurs Cfimtat,t

lnt*rnzati*n:
&,,Julr; fa,'s

praterred ffi*tk*rJ of *antaet. ttick an*)

il Mail

dernalZ

Emair address,

Fax t"{urnbeT

hriuil

ffi

Jlacsimtte

ko+l*;,^e bfocLrh^ G gm"i

L;

:

*anlact Uetall*.

&usiness t'l*urs:

*a*

"itt* aentact

&dult & at work?

ls Adult E usually home

lticl.t d, *,

during

{r*"

business hsurs? {tick}

workrerephoneNo:

O4Z

11 bla

tr

No

8 71 5 5 8 8

9th*r Wark *an:act
int*rrna?"ian:

fr,{t*r t"{ryurs:
ls Adult B uoually honre

bu*inesshatlr$?

AFTER

tti{k}

Harnerezephone?,4o:

J,
uYes

J

Na

Oh?fi 7 a65 *

g>

Atker &.tt*r frrsur'n *arlta*t

lnf*rr*ati*n'.
&"du|t

*'*

pr*t*rrad w'tetkod o, ,;.ryr*aet: tlick ofie)

J*
* Email

f) Marl
Emair address,

€vn a'.\

6

ffax Y$arnber:

? ti{,xa {V'r *rnil"y

trlailvtg Atjdrc*s

A

Facsirnrle

ni, t \. q rn Lte n n elS

5,,

Wrrt*"A..s A.\s*va ,i
74*, &

re

sari'e as Fantily llorre A.ddres,v

9tre*t ar ?* ffi*x

h

lq

.%uTsur?s'.

*taZ*:

?ost**rie:
Tzrntly *oct"cr

f yifTgf1 lif rU

bactar'*t*arne
74*.

&Stre*t*r ?fr &*z.No.'.

t

(fuLl6dividual ar Gr*up?raatz*e:

l-t r

A,rn?suZan*,e

t-u
Postcode:

Utq R ?r 5

gubsc.rzptl*n:

trs

lr.ic?"1 {f ea }

tn'sicalt: if yau r*qt;ue a

*&mF FryWM

l-.a*t u*dat*rJ

2{j-

*.nl*r'nb*r-A6

Ci7lt: ap?licati*n

{tae.$<b

sOL g

q+ta l Sq
'**e

Faxuurnber

S
l,la

?&edicare?4araber:

mruW*&TA*f\A %T&Tffi U&fffiPffi, %W*mT%, &?4m W%*Ltru,%Ary?,&ffi
TlCf,.the l:r:x lselrsvt

(tiek} E lndzttidwal #ur*p

Per

C-

r*t*phan*Nur*bar Q
*urrent

L

(Crr E€ru <

ZUfr

Y** ellFront
$tate: V

IYIgn, (.{

ksrrrr rsr car*ar:Li.he

ffiu"-r\&ru

Z C41l 3 5

q*emY\

e*fieral Affice tar mrsr* ir,t:rn'taLt*;,.

m

*aae 5

ve.rsian

7..1

pft,w.ARY T&,W"Relationship

tuiam*

Telepb*n* eon%et

LanEuage Sprsken

(Neighbour, &elative, Friend or Ath*r)
1

2
3

lft e.npit*h \ftr)te

JaNx't Ln r.rq NIt4n FBre* u
o+s8 lLL-LJ
tRr En rr
Teurcrl-t br*
)LoK 450 ot
[li(nr{uq ku. ynl\ Artr.rr (+" Q^.r"\ 04,34 Lg,zz )-5

"Y.")

"E

L
G

4

Pftl{'$&ftY f&{bqtL"Y ffit,-!*lk G &fifrRCSS:

Vtlnto"A*
t0
hbav*" il" lhe *d::* as
W*. &

$tr**t or 3* ffi*x

Tamtt',1

H*we h*cress

4s Asov€

&uburb:

7**te*de:

%tate'.

&T t", xft

r ftJr,# p, ft Y r&w t t-v fr trT &, t*g

A Sbp-Tarent
fte1ati*n*hi7s at kdult & ta $Zudent: {lick *re1

Reiat[onship ot Adult B to 9tudenti (tick one)

.$end

La*t

un

**rre*p*ndence addr*ss*d

dat*,J : 25 - S a *t*m?s er -a&

r"ot (tic*.

*rie)

tJ kd*Vstiv* ?ar*nl

L} Faster Tarent

J

7an:ily

l)

lz.*lati.t*

LJ

*th*r

;

FastrTr TarrcnL

|i i)ell
rJ Sl*p-Tar*n1
IJ ?tr*slf antily

f)

Fri*n,J

A.9e1{

)

Adtslr,

*ars* 6

k

fS

L4a*1

/\dul13

i{Urst"lt

f) Adapttue Tarent
A fteb1tu*
l1 {}th*r

A:"\ul\fi

ii

?iettker

v{:r.*i1n 2.1

0Q

ffi trfi$

W

ApH

t

*

fi gT&t t*s *

r

sT u a E/\&T

t lp which country was the student born?
{Australia
n Other (ptease speciry}:
*at*

of arrival in &,ustratrza Qft" Uate of return t{t &"u&t.ratia: {<id^mm-yyyy}

What" is

ths na$idemtiat &tatu$ {}t tfu* *tude{rt?

&asls at A^ustral\arz {4esidenc'g

il../^Hermanent u lemparary

1.tz*k}

;

fi

f

n

Holds ?ermanenl Restdency \lisa

1

tiginte for Australian Passport

Wisa

*u:*

\lisa

$tatisLl{:aX

?1rs1drt

lt t-t*tr aiia,n 7 a*spart

VisaLxpiry Wate: tdd-mrn-yyyyl

Ctr**s',

*rtrlc:

_l

_l

_

/,?,equir*d far :srsrr* $.ub-clesge*)

lnt*rnati*na| fitudqnt t*

.l?4o,"

requirerl i,.;r *xr:hange sludent.*)

& ffiae*

i

t?1*.) etudent *p*ak a tranguag* *tt1{,2:r than 6,nqlz*k at. korn*? ltic?,)l
ll mpre lhtr' r:n* latguapr: t9 ;prsftsn ir,, ffi,T,tt, indicat.* ,,ne ane lhal ir spaken rna{," 4?Len'i

*{

No. e:;<, ,:,'.

t,nry

i:

D*ea the ntud*tlr- apeak *ngliah?
a'ztrr*

tke

qturJ*{1?" o:t kbarirSznal

qr

W

Y,;a {plea** sp*Cifyl'.

(tict"t

7*rr**

U { **

9tra?t l*land*r *rigtn?

tl.tc,k

}

?4rs

''t,iffi.l#,

ane)

il llo

l)'{r:*, Ab*riginat

U Y*s;.7arre:; $trail l*lan'd*r

l) {e*.

&rsa;.?t

f:tls*rilSutal ?zTrsrres $lreil. lnlanr}*r

Whgt is the student's living arrangements? ltick *ne):

C Ur ro*"with
{1

kt hame wih

*

lnd*penrJenl

J State Arranged A$ af l4arne Aare # {8** tiat*}
J frameleeaYauth

TWO Parentsl Guardlans
A?4C.

?arentl Guardian

:tl

b*ginntng

rsf

lrsur**y

t* school:

-)

{&ap ?4urn?**r

'icfr.*ada I Ccunlry

MapType

/'

X W"eter*nae

T

fie

Ar.tlhariiy I {}ther

ft,*t*r**ce /,

Auual rn*rJe *1 t"r'an*p*rt 2e *ehaoti (l1ek)

AWaking

[) Scka*i *u*

*Train

l)

J

d?uL:ticL*tss

{3 Trarn

{7 .*r*l:f Drtttert

11

Eicycle
s1tx1*nl drn/*$ tf*rnfielf

t* *ch*al.

Car ft.e7. Na

ATaxi

Arizt*rt

Dtstanc* lts 9*ha*1

J
izt"

At?wr

kilam*tr*e^

4. T?w*t: qu*slian$ are ez?ted. a* a r*quirement *f the Ca*:rnanv.t*aftn {io'lernrrl*nt. All *r:ltrtal."i ar:tos,c; Australtz are requir*d tt}
r:allr:rJ;.

1..

ll:* $am*

a*t. ts7NlatorL.

7

int *rrrlat-i{}n.

*Y: 2*1 &

page

1A

TC w*r*i*n Nrs 2

se,.,CIoL DxTp"ff^s

*at*

3lr I t 33

of first *nralnzent in an fzuatrahan &ahaal:

Nam*rl€previau*$*haryZ:
Year%

*t pr*vi*tz*

Ct- i FfqN

rur- ?erYPO
V,{ha?"was t?w langwag*

e,Jw*ati*n:

*oe* the student" have a Vic*orian $tadent

PP,N c

ot

FlNAvts

{V**,bui

the VSN is

unknown

lJ

?1ease

ls the student wpeating a

*riu*,aLr*n:

Will the studentbe att*ndingthis schooi tull ttrne?

y*ar? {lick}

{"V**

{tiek)

lf Na,wkalwillbeth*lirne{ractiontrhatthestudentwillbeattendingNhisschaal?

*th*r

s q,?z*oa

ra***,

bla"The sturi*nt has never been

issued a VSN.

ruamananmm

V*ar at i*t*rrupti&* t*

rrs H rur. Ss.r^r

?{umber lV$?,tt?

Ye*.
*pe*ify:

n

fi

Tirne

Na

{ie:A.8=4dayslweek}

A.

ffik$!.6L_W{l-

D

traeXtarr: *

Enralle* U Yes JNa
Enr*ltred'. J Ye*

l7 h\*

*&,'d w{T.tCI r'4 e,* gN ft*Lfr# ENT DNTA{!-S
ln same cirasrnstances a child may ba *nralled candtttanally, particularly if the requzr*d snrqlz"aent da*umentatian ta deterrnine

th*sharadpar*ntalresponsibilityarrange{nentsf*ra*kildi*natprovided. Pleaseretertalke*ck*al?*1icy&kdvi*aryGuide's
AtSrnirsr;ion page

far rnore infarrrtati*n
{http:/irwvw.education.vic.qov au/sqhoolrprincipals/spag/particioation/Paqes/admls_qion.aspx).
Enralrnent candittans
&

1...it r:,|t.

ttV:la|*rJ.'l: r:ls 2A 1 6

page

11

TC verstan

t

l*

2

-

fr.TLI*#T4T &CDtrSS CItr P,CTIVITY ftffigTft'EWAM9 frtrT&ILS

15'thc lttude'r' at

t* tfuere

risk?

&ffi P,e*e$%

J

&"|*rt {ar tke *tudent2

&*

'( eg

C) Y ea {tf Ves, then camplete the
fallowtng questions and pre*ent a

itirkl

d Wa trc Ne, rr,ave ta the irnmunisalian
I medical candition detail$ questions.)

eurrent eapy of the dacument.ta the
schaal.)

AceessType:
Tl*.s

1s

cribe

s77tg

{ttek)

A Caurt

ft.*t:egs ftegtrir:ttt*n

Order

*rder fi

J

bamily Lavt

Cl

Y *ra

dto

Y

rJ N*

Restra;ining

*rder

*

Other

:

there a* &,*ttivzty Alert f*r the $tudent?

(tick)

lf Yec, then descnbe the fi"ctivily Restriclion.

d*curn*nl rsl***,J an

.sludent.

ffie? A

ln the event at tllness ar injury la my chlldwhrl*t"atschaa[ an an a,xeurciryn, ar trav*llingta *r frarfi **koal; I
authartse tke ?rincipal ar teacher-zn-charge af r*y child, where the Principal ar t*ack*r-in-charge i* unable to
*'*ntact" {Tw, ar tt t* atherwis* unpracticable ta a*ntact me to: {er**s *ut any unac**ptable *taternent}
w
cQnsenl"t* rny child receiving su*h medical *r *urEieatr att*ntian as {nay ?s* d**rned nee*,*sary by a

'

m*dical praclttian*r,"

'

.fi tgnatur*

arJ{ntntst*r such first aid as tke Trinctpal ar staff rn*rrtber rnay judg* ta be r*asanably neeessary.

e:f ? ar*nil Auar

L.e*t updated:

F*N:s

?{}10

*ate

diarr

page 12

Z

r iD ,lb

TC vercian ?4* 2

% T t-t fr

f'fr fr P,

ffi l,l T

**e*

Z?z*

t

L#

studerrt *utter fr*m any *t th*

***u the
ltathrna

e & t* n trT p,

4*tr\*wrng

UY**

l"'l*arin"rS:

l*

aYe*
b he

tL'$ent sutter tra{fi h,*,thr"'w? &ick1 lt N*, plea*e aa

Na

{tq*
::,ec*,irsn

A,-her kl*dieal C*nrlitian*,

**ndi+,ian fiel.ailr*.

T",Aedir:al

An*:'w*r t.h* t*llawtng qt-t*r;tian* *r"x,*y if tk*. *tud*n't *uffer* fr*m any a*thrrta rn*dical
atlx *h *4 Ar,th nta ?',4 a n
nt. Plan
?lease indicate it the studefir. sufters frar* any o{ the tollawing
syrfip\avrre: (lisk)

ln{arrn

Doctar

Can\act
Pllrrrinister ?rfzedication
AtherMedical Aciian

Exhrbits syrnplarns after exerlian

JTightCtwst"

medicatfir'?

tfue srudent"take

itici,l

I

3

C Y*$

?trs

74azn*

*t ,fiedieati*r,

taken'.

zn

\ndte,at* tke u$aat d*xage of
zn*ditatian tab,en'.

Xndieate ?z*'w trequently
nzedi*ati*n i* taken:

M*rh*ati*n t* u*ually arirninz*tered by:

*tar*d:

it.:r:ki

Uasagetznte I
e

r

hl

C a r' riiii

*ri cal
t

?'itare c*Diea at

U {*a
lJ 74a
DNa

nYes l UNo

pravided t"a *fua*t?

l* tke rnasii*ati*rx te'fls* regularly by th* xtud*nt (preventive) or anZy
ev*tfrter{t*? {.ti*k}

Alh

lrto

lt yes, please apecify.

*4as an lz.sttxrna Warzag*m*rtt. Tlan been

{&edzeatian t$

[

dV*t
{r*u
dV**
d'Yes

lntarrn Ernergency

[fWheeze

*o**

*n*ditiont. ?1*a** **r:

tt my child displays any at these &rff?ptama pt*asei \tick)

J Caugh
fr Attricult:y frreatktng

J

lJ T **

r:t r',

r*op*ns* ta

ilStudenl

ittc?,'1

| ilNurse

Stt:Ce*' I l) vt*h lkxse
TJY*a f ;S f,Sa
IReminderrequired?.tc\t
l)

vLilh

1

J

U TreuerLit"iv*

7,*rtp*r.,a'*

L?t*

J }ther

lJTeacher

i-i {'r,rkSe . $leit, n;t,-

A Ll*e,w'ner*

1

$ ?*t**nft"atznr4

o

lhe *tnctr r,edicai ccri{lir.ian

fram lhe sch*al

ffiYes Ae

fraes tkry student have any ather medical eandition? {tick}

lf yes, gleasa specity'.
*yrn7s\ant*

lt rny ekild dt*play* an'g *t the sllrn?t*me a?s*v* pleas*: (ti*ki

lrirsrrs Drsctor
/:"drnirilstr:r

tt4

* r|ir,ati* n

l--tr

Yec

J

74*

I

L_l

t'r:

Ather Mediaal Acttrtn

nf a r m

irn*

r ge

ncy

C

* \eS

* ntact

'"J

Yt:r;

J

ft.e*p*n*e

t)NA
i--1

tirs

ll yes, please specify:
foe$ the student take rwedication?

{.tick}

D

Yes Mo

Wanne

ls the rn*dication taken regularly by the **udant {preventive} ar anly in
symproms / iilcK)
trnriieate

th* usual do*age

rst

m*diaats**

i*

Medicaiion is usually admin;stered by:

(tick)

?&edtr,atian i*, *torerS: i,lrc?.i

l),ailk Student
*.*rnind*r r*quired?

sTa wffiwT
La*t

re parr e ta

I

preventative

ln$ieate ?z*w trer4u*r"'&ly th* rnedt*ati*n

,aken.

m*eaqq tima

at rn*dt*ati*rz tak*rz:

1&keni

tI Student

{lick}

n Nurse

Tlv'riln Nurs*

tJ

Y**

lJ t'la

*

fI eacher

f ficge rn )Ian

ll.aarzt

tr

Other

l)

ebewlwre

?az*an W.ating

ffi#*Taft atrT&t t^s

urSrJut*rJ: Fra?s

?{}1fi

page 13

TC vrtrsirsrs

?4rs

2

&,Q

CU*ffi\.&T D*.&v* p,^?"&,T lAF&

ln tha *vent of illness

CIr injury to rny chilcl whilst at $chaal, on *xcursian, a{ trallellifig ta or fram schorsl; t authorise
the Prinaipal or teaaher-in-charge of my child, wkere tke Principal ar teacher-in-charge is unabl* to cantact me, ar
is ath*rwis* impracticable ta contact rne to:
* Cans*rltta rny ehtld r*e*iving such medical ar surgical attenZian a5 may b* d*erned nece*sary by a rnedz*al

pra*tztianer,

"

kdrntnt*t*r such first atd a* the

*irlnat"sr* *f

7 ar

4pal

*r *t"att rn*nsb*r r*ay ju*g* t*'** r*a**rzably n*r****ry.

natea_8

*n, I Guar dian"

LA e p,?- ew"E

h

_ela_

w71&LJft,SWbe&

Fr*rn tirne ta time toachers will accampany clas*e* *n exewrsians withzn *ur lacal ar*a and ta all T* annual event*,
in*lwding tk* swtmrning carnival and athleticc carnival. TC'lacal area' is baunded by *heakarr* ftaad, fr*naaster
ftaad & ffilackburn ft.aad.
*tudant*twryw1d usuan\y walk ar take publiclransparl"an such excursi*ns. Par*ntslguardians'.*taald rec*tve a nat*
autlininE the details, bwtw*ulrL nat" need ta return a p*rrnission slip.
I agree

th*t rny student" can pa*icipate in l*ca\ area axcu{etans and annual *vents far tk* durati*n af th*ir

enralment. at"TC.

sisnatur*of?arenttEuardian

fiM

puBLrQ4'.ytQ**

mate

8 -fl,-Lb-

qr &r Jryrywv ryweTryryry,^p\ry &wry y?4\tww&qw,w"

giv* p*rmis*ian for photagrapk* of my child andl*r tkeu sahaal w*rk, ta be u*ed f*r prarn*ti*n at TC and
edu*ati*nal purpases. ?hafographs may b* publisked ** vw*b sttes, tn przntpubli*atian* and multim*dia
pr***ntatians.
I

$isnatare

ar parenusuardian:

t'1461-

*ar.*

g )L )A-

f*r taking tk* tirn* t* c*mpl*te this .*tud*nl" ff"nr*lrnont {arrn. W* tutrierstand Zhat" t?t* irzfrsrmation y*u
h*'a* pravtd*d is *anfidenttal and "witrn be **at"erl a* *tsah, butt"h* a*tail* ar* r*rSuir*d trs *rt**l* *tatf trs pr*parly

Than?. yats

*nrrs1 yrsur r.htlrJ at rsur

2

C*rt1fy t.hal

*ignatts

r

* *f

L.a*l urpdater)..

srk**l

th* tnt*rntar.i*n c*rl,ain**

? ar

*

nlJ

F r*?: 2A 1

v,tithin

tki* farm i* carrert

8_ tiQ,t

Guar dian.

I

page 1fr

TC versiart f4* 2

I

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hnttralta.

Valuation andTORates Notice

PO Box 168
Riehmond 3121

,t*rrrr#

Yl{RRA

FOR THE PERIOD 1 JULY 2016

30 JUhIE 2017

Phone: (03) 9205 5555

Fax; (03) 8417 6601

ABN 98 394 086 520
Ausdoc DX 302S5 Bichmond

www.yarratity.vic. gov.au

Ernail: info@yarracity.vic.gou
Date of lssue ZglOBlZ0l6

r,ffi rrhthHltllIl!n,trxr!!lH,,lt,

Witrliam Eldred Hennessy &

Katharine Alvena Hennessy
32 Council St
CLIFTON HILL VIC 3068

Property

f,il

DUE BY 30 SEPTEMBER 20.I6

Number y2g11s

INSTALMENT AMOUNT PAYABLE

$703.42
fi |

ilHfi Bfit*tff EHt$tBtf; Efl[ Ets

Payment in full by 15 February
2017 is no longer offered as a

payment option

Property Location
32 CouncilSt Clifton Hill Vl
Lot 5 LP 41147 Vol 8228 Fol 954

Scan this QR Code
to reoister for
e-NoIices or qo to
yarracity.fornisport.com.au

e4Lw'?u,r./uu
nlE i\i!/\
d

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Fire $eri:ices Pi"operi); Levy
Fire services Property Levy Residential Variable i.0000s9 x $1,310,000.00i
General Rate 0.040109c in.$ on

NAV ..:\

/lt

$105.00
fi77.29

v

$2,S27.13

,\t

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Av{
TCItal

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arnount
Option A

PAYMENT OPTIONs

Four lnst - ments

Biller Code; 171074
-rri>
Reference No: 129255 6

fr:r rie.t*iis)

{5ee

{See r*verse

Af'IIO{JNT

Billpay Code: 3006
Billpag Ref: 1292 556

P*st

7

pay in-store at Au5tralia Post, online at aurpost.com.au/
postlrillpay. by'phone 13 18 16 or via AusPost app.

017

17fiAt2A16
15t11f2Q16

15t1A2A16

$n1t2fr17
$laa2017

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$702.00
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15$)5t2Q17

.3006 1292556

1510$2:A17

:neporder payaUe to Chy of Yarra. Receipts will not be issued for mailed payments.

Gpo Box s217 MELB,,RNE vrc

\rffi^
Property No.

Drawer

|ffiil[[H[]l

32

Date

lntemal use only - Property Number

129255

Property Address

Ratepayer

300i

Council$t clifton Hill

vlc

3ffi8

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.ii:i$fliii..i,.iifiii

iii

Amount Paid

lnternal use only 'i- lnstalment amount

William Eldred Hennessy &

$2,809.42

Option B
Approved Direct Debit Payments

Eranch

$

for details)
AMSUI.IT

$280.42
$2S1.00
$2S1.00
$281.08
$281.00
$281.00
$281.00
$281.00
$281.00

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