Application for an Exemption Certificate Use this form to apply for an Exemption Certificate from the ACT Education Directorate

Please contact the ACT Education Directorate on (02) 6205 6759 or email ExemptionCerts@act.gov.au if you require any assistance completing the application.

Step 1 Details of child/young person Name (in full)

Address

Suburb

Postcode

Date of birth

Age

Gender

Current year level at school

Is the child/young person an Australian citizen or

permanent resident?Yes No

Step 2 Details of parent/guardian/carer Name of parent/guardian/carer 1 (in full)

Address

Suburb

Postcode

Telephone (business)

Mobile

Email address

Name of parent/guardian/carer 2 (if applicable)

Address

Suburb

Postcode

Telephone (business)

Mobile

Email address

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When applying for an Exemption Certificate please note the following:

Exemption Certificates are only issued in exceptional circumstancesExemption Certificates will generally not be backdatedExemption Certificates will not be granted for a period longer than six months except in the case of work related training or employment alternativeAn Individual Learning Plan (ILP) must accompany an application for partial exemption The application must be signed by all partiesAll decisions regarding Exemption Certificates are reviewable.

Yes No

Yes No

Step 3 School detailsIs the child/young person currently enrolled or ever

been enrolled in an ACT school?

If yes, please provide:

Name of school attended

School Principal's name

If no, please provide:

Name of last school attended

Which of the following apply to this child/young

person? Accessing a disability education program

Identify as Aboriginal and/or Torres Strait Islander

In Out of Home Care

Culturally and Linguistically Diverse (CALD)

Registered for home education

Approved for distance education

Yes No

Step 4 Period of exemption requested Period of exemption requested

Start date Finish date

Full-time exemption Yes No

Part-time exemption Yes No

Step 5 Reason for Exemption CertificatePlease indicate why the child/young person seeks an exemption from the full-time participation (attendance) requirement.

1. An Apprenticeship/Traineeship with no Year10 Certificate

Yes

No

2. Enrolled to study at the Canberra Instituteof Technology (CIT) or private Registered TrainingOrganisation (RTO) with no Year 10 Certificate

Yes

No

3. Exceptional circumstances preventing full-timeparticipation (attendance) in education

Yes

No

4. No Year 10 Certificate and pursuing acombination of part-time training/work/education

Yes

No

5. No Year 10 Certificate and pursuing full-timeemployment (over 25 hours)

Yes

No

6. A graduated return to education Yes

No

7. Other (provide details below) Yes No

For all applicants seeking an Exemption Certificate, please provide a clear and comprehensive statement below to support the application.

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Yes NoNo

No

Yes

Yes

Yes No

Step 6 Supporting documentationPlease attach any additional documentation to support this application.

1) All applicants are required to provide:A certified copy of the child/young person’s birth certificateEvidence of place of residence, for example a certified copy of a rates notice/lease/electricity bill/water bill or similar

2) For a child/young person who is not an Australian citizen or a permanent resident please provide:A certified copy of the child/young person's passport A certified copy of the child/young person's current visa

For the child/young person who: - Is subject to a family law court order, please provide a copy of the order.

- Is undertaking a full-time apprenticeship/traineeship, please submit a copy of the training contract.

- Is studying at CIT or with a private RTO, please submit a copy of the CIT/RTO enrolment form or acceptance letter.

- Is under 15 years of age and has employment, please complete the employment details section below. Please refer to the Community ServicesDirectorate information page at www.dhcs.act.gov.au/ocyfs/young_workers#young. Include the Parental Consent Form in this application.

- Has exceptional circumstances which prevent full-time participation (attendance). Please supply supporting letter/s e.g. from a medicalpractitioner/psychologist or other professional/specialist.

- Is undertaking either full-time work/part-time work/part-time education/part-time training (or a combination of these options), please complete theappropriate sections below and provide details of the hours of attendance for the intended part-time education.

Employment detailsType of employment (retail, hospitality,

hairdressing, building etc)

Business name

Employer’s/Supervisor's name

Address

Telephone

Email address

Start date

Indicate the number of hours of work per week

Training/Education details Training/Education provider

Contact name

Address

Telephone

Email

Start date

Indicate the number of intended class hours

Indicate the days attending training/education

per week

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Step 7 Supporting documentation from the schoolExemption from the full-time participation requirement (attendance) for five school weeks or more (i.e. greater than 5 weeks/25 school days/150 hrs) requires a clear and comprehensive statement from the School Principal to support the Exemption Certificate application.For a child/young person who is requiring a graduated return to school, please provide details of the return to school plan including a copy of the ILP.

Principal's comment

Step 8

ConsentParent/Guardian/Carer 1 Signature

Date

Parent/Guardian/Carer 2 Signature (if applicable)

Date

Director-General Signature *

Date*If a child/young person is under Care and Protection orders this application must be submitted by the Care and Protection Services, Community

Services Directorate and signed by the Director-General.

Privacy Notice: The ACT Education Directorate is obliged to handle your personal information openly, transparently and in accordance with the Territory Privacy Principles set out in the Information Privacy Act 2014. You can view our privacy policy on the About Us page of the Directorate's website (http://www.det.act.gov.au/about_us).

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Principal's Signature

Date

The completed form should be sent to:

Exemption Certificates Transitions and CareersACT Education Directorate GPO Box 158CANBERRA ACT 2601