Education Department of Western Australia
APPLICATION FOR REGISTRATION AS HOME EDUCATOR
Parent/Guardian Details:
|Mother/Guardian* (please circle): |
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|Please tick if to be registered as |
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|Home |
|Educator |
|Mail |
|Recipient |
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|Title Last Name First Name |
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|Father/Guardian* (please circle): |
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|Please tick if to be registered as |
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|Home |
|Educator |
|Mail |
|Recipient |
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|Title Last Name First Name |
|*Please attach supporting documents detailing relationship to student |
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|Home Address |
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|Postcode |
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|Postal Address |
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|Postcode |
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|Phone No. Home |
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|Mobile No. |
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|Email Address |
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|Are there any Family Court Orders regarding the day to day or long term care, welfare and development of the child? |
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|YES |
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|NO |
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|If yes, please attach a copy of court orders for residence/access restrictions. |
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|Previous experience as home educator(s): |
|YES |
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|NO |
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|If yes, please name: district |
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|child/children |
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|Student Details: |
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|Male |
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|Female |
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|Legal Surname |
|First Names |
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|Date of Birth: |
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|Copy of Birth Certificate attached: |
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|(Birth Certificate must be sighted before registration can be completed) |
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|Last school or home education district: |
|(If none, write “Nil”) |
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|Current School Year _______ |
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|Date last attended: |
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|Curriculum Council Student Number: |
|(Secondary students - if known) |
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|Male |
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|Female |
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|Legal Surname |
|First Names |
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|Date of Birth: |
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|Copy of Birth Certificate attached: |
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|(Birth Certificate must be sighted before registration can be completed) |
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|Last school or home education district: |
|(If none, write “Nil”) |
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|Current School Year _______ |
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|Date last attended: |
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|Curriculum Council Student Number: |
|(Secondary students - if known) |
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|Male |
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|Female |
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|Legal Surname |
|First Names |
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|Date of Birth: |
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|Copy of Birth Certificate attached: |
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|(Birth Certificate must be sighted before registration can be completed) |
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|Last school or home education district: |
|(If none, write “Nil”) |
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|Current School Year _______ |
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|Date last attended: |
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|Curriculum Council Student Number: |
|(Secondary students - if known) |
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I/we understand and accept the supervisory requirements for home education (s.51 of the School Education Act 1999)
|Parent/guardian signature(s): | | | |Date: | |
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|I authorise the South Metropolitan Education Region Home Education Moderator to obtain school admission details, subsequent to home education, for the students |
|named on this application. |
|Parent/guardian signature(s) | | | | |
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DETAILS OF EDUCATIONAL PROGRAM
|Commencement date for home education: | | |
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|Reason for home educating: | | |
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|Name of education program provider if other than applicant: | | |
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|Address of place where your educational program will primarily be | | |
|delivered if different from the home address: | | |
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ADDITIONAL INFORMATION
|Student’s first language: | |
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|Language/s spoken at home: | |
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|Is the student Aboriginal or |YES | |NO | |
|Torres Strait Islander? | | | | |
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|Permanent Resident: |YES | |NO | |
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|If no, please supply copies of documentation and provide the |Date Entered Australia: | |
|following information: | | |
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| |Visa Sub-class Number: | |
|Emergency Contact: |
|Name: | |Telephone Number: | |
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|Address: | |
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Further issues/factors of which you would like to inform the moderator (optional):
Please return completed form to:
Home Education Moderator
South Metropolitan Education Regional Office
PO Box 63
SOUTH FREMANTLE 6162
Location: 184 Hampton Road, Beaconsfield
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Department of Education
Government of Western Australia
South Metropolitan Education Regional Office
[pic]
OFFICE USE ONLY
Date Received:___________________________
Curriculum Council No: YES NO [pic]
Birth certificate sighted: YES [pic] NO [pic]
Visa sighted: YES [pic] NO [pic]
Family Court Order sighted: YES [pic] NO [pic]
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