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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