Enrolment Form

Enrolment Information - Step 1 of 6

Privacy Statement

The Department of Education is committed to providing Northern Territory students with quality education services. The department needs to ask for personal information from students, parents, guardians so it can plan, provide and report on its services, and to monitor compliance under the Education Act. Personal information will only be disclosed for these purposes as permitted by the Information Act. The attached information sheet Respecting Your Privacy provides more detail about how we will use and disclose the information you provide If you need help completing this form please contact the Northern Territory School of Distance Education Coordinators.

Type of enrolment

Dual School
Independent
Medical
Travel
Mature Aged
Other

CRITERIA - Schools

To be eligible for dual enrolment the student must be enrolled in a NT or SA school that is not able to meet all of the course requirement needs of the student. Dual enrolments generally occur when:

specialist teachers are not available

student is transferring between schools with subject differentiation

school timetabling constraints limit or prevent subject choice.

Student enrolment arrangements are generally negotiated between the student’s home school coordinator and NTSDE's coordinator.

For more detail view the guidelines for enrolment in distance education schools.

CRITERIA - Independent

A student may be enrolled on the grounds of geographical isolation where they meet one of the following criteria:

The distance between the principal family home and the nearest appropriate government school is at least 56km via the shortest practicable route.

The distance between the principal family home and the nearest transport to an appropriate government school is at least 4.5km and the distance to the school is at least 16km via the shortest practicable route.

There is no reasonable access to an appropriate government school for at least 20 days of the school year because of adverse travel conditions (e.g. impassable roads) or other circumstances beyond the family's control.

For more detail view the guidelines for enrolment in distance education schools.

CRITERIA - Medical

Generally to be eligible for enrolment on the basis of special circumstances there must be evidence that the student is in receipt of ongoing treatment, counselling or other appropriate intervention.
Enrolment on the basis of special circumstances is generally not considered to be a long term arrangement. In most instances, students need to be working towards re-integration into regular school attendance or a flexible education arrangement. Where considered necessary, independent advice may be sought to ensure that distance education is, and continues to be, the most appropriate provision for the student.

The department recognises that there may be special circumstances where a long-term illness or medical condition may inhibit a student's ability to participate in the learning and engagement requirements of the curriculum. As such, parents may seek an exemption from attendance and participation in line with the Exemption from Attendance and Participation

To be enrolled on medical grounds all of the following criteria must be met:

the student has a long-term illness or medical condition preventing attendance at school:

and

medical certification is provided to validate that the student cannot attend mainstream school for more than 80 consecutive school days; and

the principal is satisfied that there are no other appropriate local provisions available to the student; and

provision of medical certification is required each year to continue enrolment on medical grounds.

For more detail view the guidelines for enrolment in distance education schools.

CRITERIA - Travel

NT student temporarily interstate or overseas or interstate
To be enrolled as an interstate or overseas NT student on the grounds that the family is temporarily traveling interstate or overseas, all of the following criteria must be met:

usual place of residence must be the NT and the family must be returning to the NT; and

enrolment is for a minimum of one semester and maximum of two semesters.

A statutory declaration must be provided stating:

the family's intention to travel;

the anticipated duration of the travel; and

the expected home address after travel.

A detailed itinerary showing addresses for a minimum of six weeks in advance.

For more detail view the guidelines for enrolment in distance education schools.

CRITERIA - Mature Age

Mature age Mature age entry requirements are outlined in the Enrolment Eligibility guidelines and require applicants to comply with the:
Allocation of Government School Education (26 semesters) guidelines; and b) Criminal History Check for Prospective

Mature Age Students guidelines.

Residential blocks only form part of a mature age student enrolment where the subject/s undertaken have compulsory practical requirements, for example, science. If mature enrolment numbers were such that there is a demand for residential blocks for other subject areas this may be facilitated where capacity exists.

Students currently enrolled who turn 18 years of age during their Year 12 studies are not considered mature age students.

For more detail view the guidelines for enrolment in distance education schools.
For more detail view the guidelines for enrolment in distance education schools.

Other please provide details:

For more detail view the guidelines for enrolment in distance education schools.

Academic Year to enrol: *

Year 10
Year 11
Year 12

School Term to Enrol *

Has the student ever attended an NT school? *

State/Territory of the last school attended

Year/grade/level attained

Date Left Previous School

Is the student in the NT due to a Defence Force posting?

Proof of identity (i.e. Birth Certificate, Medicare Card, health care card)

Click or drag files to this area to upload. You can upload up to 3 files.

Please provide the school with a certified copy

Section 1 - Student Details

Name *

First

Middle

Last

Is Legal Surname on birth certificate different from the above? *

Legal Name *

First

Middle

Last

Student Preferred Name:

Birthday *//

Gender *

Male
Female
Other

Student Residential Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Is postal address same as residential address?

Postal Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Student phone number

Student Email *

Section 2 - Additional Information

Is the student independent (living w/out parent/guardian)? *

Is the student currently undertaking an Australian School-based Apprenticeship?

Is the student of Aboriginal or Torres Strait Islander origin? *

Is a Language spoken at home other than English?

Please specify Language spoken at home

Is the student an Australian citizen/permanent resident/temporary resident?

If born overseas, on what date did the student arrive in Australia?

In which country was the student born?

Section 3 - Special Family Circumstance

Special family circumstances

Special family circumstances include a single parent, dual custody, foster care, court orders, access restrictions, etc. Please provide details of the circumstance.

Please attached any supporting legal documents

Click or drag files to this area to upload. You can upload up to 5 files.

Please upload files,

Section 4 - Sibling Information

Does the student have any brothers or sisters at this school?

Sibling 1 - Name

First

Last

Sibling 1 - Date of Birth

Sibling 2 - Name

First

Last

Sibling 2 - Date of Birth

Section 5 - Parent/Guardian Information

Parent/Guardian 1

Title *

Name *

First

Middle

Last

Relationship to Student: *

Please complete the following *

	Yes	No
Responsible for parenting?	Responsible for parenting? Yes	Responsible for parenting? No
Lives with student?	Lives with student? Yes	Lives with student? No
Receive reports, etc?	Receive reports, etc? Yes	Receive reports, etc? No
Contact this person in an emergency?	Contact this person in an emergency? Yes	Contact this person in an emergency? No

Phone *

Mobile

Email *

Residential Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Is postal address same as residential address?

Postal Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Add additional Parent/Guardian

Parent/Guardian 2

Parent/Guardian 2

Name

First

Middle

Last

Relationship to Student:

Likert Scale

	Yes	No
Responsible for parenting?	Responsible for parenting? Yes	Responsible for parenting? No
Lives with student?	Lives with student? Yes	Lives with student? No
Receive reports, etc?	Receive reports, etc? Yes	Receive reports, etc? No
Contact this person in an emergency?	Contact this person in an emergency? Yes	Contact this person in an emergency? No

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Is postal address same as residential address?

Postal Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Section 6 - Parent/Guardian Background Information

Parent/Guardian 1

The information in this section is needed for national reporting purposes. All parents across Australia, no matter which school their child attends, are asked to provide this information. It will be used to help school education authorities ensure that funding and teaching resources are appropriately allocated to Territory schools as part of the National Education Agreement.

Does the parent speak a language other than English at home?

Please specify the language the parent speaks at home

What is the highest year of primary or secondary school the parent/guardian has completed *

What is the highest qualification the parent/guardian has completed? *

What is the occupational group of parent or guardian? Please click link to view details below. *

Group 1
Group 2
Group 3
Group 4

Select the group for more information.
If the person has not been in paid work in the past 12 months, please choose 5 in the list

Group 1

Group 2

Group 3

Group 4

Group 4 (copy)

Section 7 - Consent Details

Medical Consent

Yes	No
I give consent to the sharing of health information between schools and Department of Health and Families (DHF) as outlined in the privacy statement. DHF offers student health services including nursing, dental, audiology and general health advice and provides feedback to the school after health checks (e.g. vision or hearing results) Yes	I give consent to the sharing of health information between schools and Department of Health and Families (DHF) as outlined in the privacy statement. DHF offers student health services including nursing, dental, audiology and general health advice and provides feedback to the school after health checks (e.g. vision or hearing results) No

I give consent to the sharing of health information between schools and Department of Health and Families (DHF) as outlined in the privacy statement. DHF offers student health services including nursing, dental, audiology and general health advice and provides feedback to the school after health checks (e.g. vision or hearing results)

Consent for publication of a student's Photo and Work

DoE may record sound and/or vision of a student and their work while they are at school or taking part in school related activities or performances. Photographs of students involved in activities, and work by students, are often published to enable the students to share their experiences and to enable parents and others to be informed about the school or college’s work. This does not mean that the student loses ownership of the works.

Talent Release Authority

Agree

I give permission for the Northern Territory School of Distance Education, Department of Education and Northern Territory Government to use students name, work and photographs, video or audio recordings for marketing and promotional purposes including but not limited to printed publications, newsletters, posters, advertisements, websites, social media, television commercials, billboards, and cinema and radio advertisements. Photos, video and/or audio recordings or other personal information described in this form may be supplied to the Department staff, contractors or service providers (i.e. graphic designers) engaged by us to produce these materials.

(Deselect agree for more options)

I give permission to use the following

	Use of Student Photograph/Video	Use of Work by Student	Publishing Student First Name	Publishing Student Surname
School/ Newsletter	School/ Newsletter Use of Student Photograph/Video	School/ Newsletter Use of Work by Student	School/ Newsletter Publishing Student First Name	School/ Newsletter Publishing Student Surname
School/Yearbook	School/Yearbook Use of Student Photograph/Video	School/Yearbook Use of Work by Student	School/Yearbook Publishing Student First Name	School/Yearbook Publishing Student Surname
School/Department Website	School/Department Website Use of Student Photograph/Video	School/Department Website Use of Work by Student	School/Department Website Publishing Student First Name	School/Department Website Publishing Student Surname
School Facebook	School Facebook Use of Student Photograph/Video	School Facebook Use of Work by Student	School Facebook Publishing Student First Name	School Facebook Publishing Student Surname

Consent for library use

Agree

I give consent to authorised access of the student's contact details and library borrowings by LINNet (Libraries in the Northern Territory) and associated libraries. School libraries use the contact details to provide library services to students and may share this information with LINNet and associated libraries. Only authorised library staff will have access to this information. If the information is not provided, the student may not be able to borrow from the school library.

Consent for publishing student and parent data to third party systems

Agree

I give consent to publish student and parent personal data in SAMS to third party systems where there is a legal contract in place with DoE (in accordance with IPP9 of the Information Act and NTG security policy).

Section 8 - Emergency Contacts

For an emergency where the parent/guardian/carer cannot be contacted, please provide alternate contacts. For independent students this is the 1st point of contact in an emergency

Emergency Contact 1

Title

Name *

First

Last

Relationship to Student: *

Phone *

Mobile

Add second emergency contact

Emergency Contact 2

Emergency Contact 2

Title

Name *

First

Last

Relationship to Student: *

Phone *

Mobile

Section 9 - Medical Details

Does your child suffer from any of the following? *

	No	Yes
Allergies	Allergies No	Allergies Yes
Diabetes	Diabetes No	Diabetes Yes
Diagnosed migraine/headaches	Diagnosed migraine/headaches No	Diagnosed migraine/headaches Yes
Seizure disorder (e.g. epilepsy)	Seizure disorder (e.g. epilepsy) No	Seizure disorder (e.g. epilepsy) Yes
Physical Disability	Physical Disability No	Physical Disability Yes
Asthma	Asthma No	Asthma Yes
Mental Health or behaviour problem (e.g. depression, ADHD)	Mental Health or behaviour problem (e.g. depression, ADHD) No	Mental Health or behaviour problem (e.g. depression, ADHD) Yes
Hearing impairment	Hearing impairment No	Hearing impairment Yes
Visual impairment	Visual impairment No	Visual impairment Yes
Speech impairment	Speech impairment No	Speech impairment Yes
Learning disability (e.g. dyslexia)	Learning disability (e.g. dyslexia) No	Learning disability (e.g. dyslexia) Yes
Intellectual disability	Intellectual disability No	Intellectual disability Yes
Acquired brain impairment	Acquired brain impairment No	Acquired brain impairment Yes

School staff will administer first aid, seek medical assistance or call an ambulance for the student being enrolled if they judge this to be necessary.

Others, please specify

If you have chosen "Yes" for any of the above please provide details

Medication *

	No	Yes
Medication required? Please supply details of treatments, care or medication required. (contact school for relevant forms)	Medication required? Please supply details of treatments, care or medication required. (contact school for relevant forms) No	Medication required? Please supply details of treatments, care or medication required. (contact school for relevant forms) Yes
Relevant medical consent forms completed and attached	Relevant medical consent forms completed and attached No	Relevant medical consent forms completed and attached Yes
Immunisation certificate/record provided	Immunisation certificate/record provided No	Immunisation certificate/record provided Yes

If Medication required Please supply details of treatments, care or medication required. (contact school for relevant forms)

Click or drag files to this area to upload. You can upload up to 5 files.

Name of person enrolling the student /providing consents : *

First

Last

Relationship to Student: *

Parent/Guardians signature: *

Declaration by Parent/Guardian

Date *

Message