Name
*
First Name
Last Name
Name of workshop
*
Date of workshop
*
MM
DD
YYYY
Date of birth
*
MM
DD
YYYY
Gender
*
Male
Female
Don't wish to specify
Does the student identify as Aboriginal or Torres Strait Islander?
*
No
Yes
Name of school and school year?
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Parent/Guardian Name
*
First Name
Last Name
Parent Guardian Phone (Mobile)
*
Country
(###)
###
####
Parent Guardian Phone (Home or Work)
*
Country
(###)
###
####
Parent/Guardian Email
*
Is your child subject to seizures, fainting, epilepsy, diabetes or any other condition that may affect his or her safety?
*
No
Yes
Does your child have a disability?
*
No
Yes
Is your child severely allergic to anything such as penicillin, other drugs, foods, bites etc.?
*
No
Yes
If yes to any of the above, please provide details
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).
*
No
Yes
Does your child self-administer the medication?
*
No
Yes
If yes to above, please state name of medication, dosage and frequency of use
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)
Student's images and/or their work samples are often published on Scholars 21 platforms including blogs, social media and our website for marketing and to recognise excellence or effort. This may also include appearances 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. You are of course at liberty to withdraw your consent at any time by contacting Scholars 21 administration.
*
I do give consent
I do not give consent
Student access to the internet is provided in accordance with school policy for use of technology in Scholars 21 courses.
*
I do give consent
I do not give consent
