NAME OF SCHOOL: _

UBURB:

REVISION OF INFORMATION SUPPLIE

Student Information

Change of Name Certificate, (if applicable)

(If known)

(to be used only with Principal’s approval)

(If different from Legal First Name)

(Please specify)

(Please specify)

(Please specify)

(Please specify)

V2: 11Sept2014

REVISION OF INFORMATION SUPPLIED

NAME OF SCHOOL:

SUBURB:

The Roman Catholic Trust Corporation for the Diocese of Cairns trading as St Francis Xavier’s School, Manunda. CRICOS Provider Code 02031K

Proceed to Section 5: Current/Previous Schooling (Please specify)

Proceed to Section 4: International Details

(including passport number)

(if applicable).

(if known) (Date) (Date)

If more space is required, please attach a separate page.

(Please specify)

Related Persons’ Information

(If different from Legal Surname)

(If different from Legal First Name)

(If different from Legal Surname)

(If different from Legal First Name)

(Please specify)

(Please specify)

(Please specify)

(If applicable)

(Please specify)

(Please specify)

(Please specify)

(If applicable)

(Tick one (1) only)

(for Dept. of Communities only)

(Tick one (1) only)

(for Dept. of Communities only)

continued

Additional Student Information

(If required)

(If required)

Proceed to Section 16: Student Specialist Assessments

(Please specify)

(eg an assessment by a speech pathologist, behavioural psychologist, orthopaedic specialist, paediatrician etc.)

Proceed to Section 17: Educational Support Information

Proceed to Section 18: Legal Information

Proceed to Section 19: Sibling Information

(Please specify)

Proceed to Section 20: Additional Information

(If applicable)

(If applicable)

(If applicable)

Proceed to Check List

Page 12 of 12

Check List

Please complete this Check List and attach any documents relevant to this Revision of Information Supplied form Note that original documents will need to be sighted. Documents provided:

Australian Citizenship Documentation Yes No Not Applicable Current Passport Yes No Not Applicable Current Visa Yes No Not Applicable Health Care Documentation Yes No Not Applicable Current/Previous School Transfer Documentation Yes No Not Applicable Last two Academic Reports Yes No Not Applicable Most recent NAPLAN Results Yes No Not Applicable Baptism Certificate Yes No Not Applicable Legal Documentation – Related Persons Yes No Not Applicable Health or Medical Assessment Reports Yes No Not Applicable Legal Documentation – Student Yes No Not Applicable Application Fee Yes No Not Applicable Reference Yes No Not Applicable Supporting Information (eg Folio of relevant merit certificates, awards) Yes No Not Applicable

Signature(s)

I declare that:

The information provided in this form is a full and frank disclosure of changed information pertinent to thestudent noted on this form.

I understand that:

I have an obligation to inform the school of any change to information previously provided. I have an ongoing obligation to provide the school with relevant, current information about the student prior

to, or for the period of, enrolment at the school.

SIGNATURE of Parent or Legal Guardian 1

PRINT NAME of Parent or Legal Guardian 1

RELATIONSHIP to Student

DATE SIGNED

SIGNATURE of Parent or Legal Guardian 2

PRINT NAME of Parent or Legal Guardian 2

RELATIONSHIP to Student

DATE SIGNED

D D / M M / Y Y D D / M M / Y Y

SIGNHERE

SIGNHERE

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Name of School: St Francis Xavier's SchoolSchool Suburb / Town: ManundaLegal Surname: Preferred Surname to be used only with Principals approval: Legal First Name: Preferred First Name If different from Legal First Name: Other Given Names: DOB: CES Student ID: Gender: OffAustralia: OffOther Please specify: undefined: OffEnglish: OffOther Please specify_2: undefined_2: OffNo: OffYes Aboriginal: OffYes Torres Strait Islander: OffYes Both Aboriginal and Torres Strait Islander: OffNo English Only: Offundefined_3: OffYes Other Please specify: No_2: Offundefined_4: OffYes Other Please specify_2: Australia If the student was not born in Australia or the student was born in Australia and the parents were not born in: OffOther country: Other Country Please specify: OffCountry of Passport Issue: Date of entry to Australia: Visa SubClass Number: Health Care Number: Visa Expiry Date: Health Care Expiry Date: School name 1: School Suburb 1: School state 1: School contact number 1: School year levels 1: School attended from 1: School attended to 1: School name 2: School Suburb 2: School state 2: School contact number 2: School year levels 2: School attended from 2: School attended to 2: School name 3: School Suburb 3: School state 3: School contact number 3: School year levels 3: School attended from 3: School attended to 3: Is the Student Catholic: Offdetails of any Sacraments Received are provided below: Baptism: OffBaptism date: Date Received DD MM YY Parish: Suburb: Reconciliation: Offreconciliation date: Date Received DD MM YY Parish_2: Suburb_2: Eucharist: OffEucharist date: Date Received DD MM YY Parish_3: Suburb_3: Confirmation: OffConfirmation date: Date Received DD MM YY Parish_4: Suburb_4: Legal Surname_2: Legal First Name_2: Other Given Names_2: Preferred Surname If different from Legal Surname: Preferred First Name If different from Legal First Name_2: DOB1: Legal Surname_3: Legal First Name_3: Other Given Names_3: Preferred Surname If different from Legal Surname_2: Preferred First Name If different from Legal First Name_3: Title: OffTitle_2: OffGender_2: OffGender_3: OffDOB2: Australia_2: Offundefined_5: OffOther Please specify_3: Country of passport issue: No English Only_2: Offundefined_6: OffYes Other Please specify_3: No_4: Offundefined_7: OffYes Other Please specify_4: Religion: Parish of Worship If applicable: Australia_3: Offundefined_8: OffOther Please specify_4: Country of passport issue 2: No English Only_3: Offundefined_9: OffYes Other Please specify_5: No_5: Offundefined_10: OffYes Other Please specify_6: Religion_2: Parish of Worship If applicable_2: What is the occupation group of the parentcaregiver: Year 12 or equivalent: OffYear 11 or equivalent: OffYear 10 or equivalent: OffYear 9 or equivalent or below: OffBachelor degree or above: OffAdvanced diplomaDiploma: OffCertificate I to IV including trade certificate: OffNo nonschool qualification: Offnurse pensioner student: Regional Council Cairns Hospital Coles: Interests: undefined_11: What is the occupation group of the parentcaregiver_2: Year 12 or equivalent_2: OffYear 11 or equivalent_2: OffYear 10 or equivalent_2: OffYear 9 or equivalent or below_2: OffBachelor degree or above_2: OffAdvanced diplomaDiploma_2: OffCertificate I to IV including trade certificate_2: OffNo nonschool qualification_2: Offnurse pensioner student_2: Regional Council Cairns Hospital Coles_2: Interests_2: undefined_12: Street Address: SuburbTown: State: Postcode: Country if not Australia: Same as Residential address: OffPostal Address: SuburbTown_2: State_2: Postcode_2: Country If not Australia: Street Address_2: SuburbTown_3: State_3: Postcode_3: Country if not Australia_2: Same as ParentLegal GuardianCaregiver1: OffStreet Address_3: SuburbTown_4: State_4: Postcode_4: Country if not Australia_3: Same as Residential address_2: OffPostal Address_2: SuburbTown_5: State_5: Postcode_5: Country If not Australia_2: Street Address_4: SuburbTown_6: State_6: Postcode_6: Country if not Australia_4: 11 Home Telephone Number: person: undefined_13: 11 Mobile Telephone Number: undefined_14: undefined_15: Email Address: undefined_16: 11 Work Telephone Number: undefined_18: undefined_17: 11 Work Mobile Telephone Number: undefined_19: undefined_20: Work Email Address: undefined_21: Comments: 11 Home Telephone Number 2: person_2: undefined_22: 11 Mobile Telephone Number 2: undefined_23: undefined_24: Email Address_2: undefined_25: 11 Work Telephone Number 2: undefined_26: undefined_27: 11 Work Mobile Telephone Number 2: undefined_28: undefined_29: Work Email Address_2: undefined_30: Comments_2: Mother: OffHome Stay Sister: OffFather: OffHome Stay Brother: OffStep Mother: OffAunt: OffStep Father: OffUncle: OffFoster Mother: OffNiece: OffFoster Father: OffNephew: OffGrandmother: OffCousin: OffGrandfather: OffFriend: OffHome Stay Parent: OffDoctor: OffSister: OffDentist: OffBrother: OffLegal Guardian for Dept of: OffHalf Sister: OffCare Provider: OffHalf Brother: OffCounsellorSocial Worker: OffStep Sister: OffAgent: OffStep Brother: OffReg Exchange Org: OffFoster Sister: OffFoster Brother: OffMother_2: OffHome Stay Sister_2: OffFather_2: OffHome Stay Brother_2: OffStep Mother_2: OffAunt_2: OffStep Father_2: OffUncle_2: OffFoster Mother_2: OffNiece_2: OffFoster Father_2: OffNephew_2: OffGrandmother_2: OffCousin_2: OffGrandfather_2: OffFriend_2: OffHome Stay Parent_2: OffDoctor_2: OffSister_2: OffDentist_2: OffBrother_2: OffLegal Guardian for Dept of_2: OffHalf Sister_2: OffCare Provider_2: OffHalf Brother_2: OffCounsellorSocial Worker_2: OffStep Sister_2: OffAgent_2: OffStep Brother_2: OffReg Exchange Org_2: OffFoster Sister_2: OffFoster Brother_2: OffEmergency contact 1st: OffEmergency contact 2nd: OffEmergency contact 1st 2: OffEmergency contact 2nd 2: OffEmergency contact: OffEmergency contact 2: Offdocumentation must be attached: Offdocumentation must be attached_2: Offstudent on a daytoday basis: Offstudent on a daytoday basis_2: OffA student must have one 1 main contact: OffA student must have one 1 main contact_2: OffReport cards: OffReports 2: OffNewsletters: OffNewsletters 2: OffInvitations: OffInvites 2: OffSchool Portal: OffPortal access 2: OffDoes this person reside with the student: OffDoes this person reside with the student_2: Offinterpreter: Offinterpreter_2: OffSame as ParentLegal GuardianCaregiver1_2: OffSame as ParentLegal GuardianCaregiver2: OffStreet Address_5: SuburbTown_7: State_7: Postcode_7: Country If not Australia_3: Same as ParentLegal GuardianCaregiver1_3: OffSame as ParentLegal GuardianCaregiver2_2: OffStreet Address_6: SuburbTown_8: State_8: Postcode_8: Country If not Australia_4: 14 Student Telephone Number: student: undefined_33: 14 Student Alternative Number: student_2: undefined_34: 14 Student Mobile Number: undefined_35: undefined_36: Email Address_3: undefined_37: Yes Provide details below: OffNo_26: Offundefined_38: Offundefined_39: Offundefined_40: Offundefined_41: Offundefined_42: OffAllergy: undefined_43: Offundefined_44: Offundefined_45: Offundefined_46: Offundefined_47: OffAnaphylaxis: undefined_48: Offundefined_49: Offundefined_50: Offundefined_51: Offundefined_52: OffAsthma: undefined_53: Offundefined_54: Offundefined_55: Offundefined_56: Offundefined_57: OffDiabetes Mellitus Type 1: undefined_58: Offundefined_59: Offundefined_60: Offundefined_61: Offundefined_62: OffEpilepsy: undefined_63: Offundefined_64: Offundefined_65: Offundefined_66: Offundefined_67: OffFebrile Convulsions: undefined_68: OffOther Please specify_6: undefined_69: Offundefined_70: OffOther Please specify_5: Yes Provide details below and ensure a legible copy of any relevant health or medical assessment: Offundefined_71: OffNo 1: Respond: Offand or participation in school 1: Has the student been diagnosed with a disability If so provide details 1: Independent Schools Queensland or Catholic Education If so provide details 1: If the student is from interstate or overseas describe the educational support provided 1: Is the student in Care of the State: Offlegal issues: OffParenting Order: OffParenting Order_2: 18 Date 1: 18 Date 2: Parenting Agreement: OffParenting Agreement_2: 18 Date 3: 18 Date 4: Domestic Violence Order: OffDomestic Violence Order_2: 18 Date 5: 18 Date 6: Apprehended Violence: OffApprehended Violence Order: 18 Date 7: 18 Date 8: Child Protection Order: OffChild Protection Order_2: 18 Date 9: 18 Date 10: Other Caring Arrangement: OffPlease specify: Other Caring Arrangement Please specify: 18 Date 11: 18 Date 12: Legal Guardianship: OffLegal Guardianship Documentation: 18 Date 13: 18 Date 14: Sibling info 1: OffSibling 1Row1: Sibling 2Row1: Sibling 3Row1: Sibling 4Row1: Sibling 1Row2: Sibling 2Row2: Sibling 3Row2: Sibling 4Row2: Sibling 1Row3: Sibling 2Row3: Sibling 3Row3: Sibling 4Row3: Sibling 1Row4: Sibling 2Row4: Sibling 3Row4: Sibling 4Row4: 19 Date 1: 19 Date 2: 19 Date 3: 19 Date 4: D D M M Y Y Y YRow1: D D M M Y Y Y YRow1_2: D D M M Y Y Y YRow1_3: D D M M Y Y Y YRow1_4: D D M M Y Y Y YRow2: D D M M Y Y Y YRow2_2: D D M M Y Y Y YRow2_3: D D M M Y Y Y YRow2_4: D D M M Y Y Y YRow3: D D M M Y Y Y YRow3_2: D D M M Y Y Y YRow3_3: D D M M Y Y Y YRow3_4: undefined_72: Offundefined_73: Offundefined_74: Offundefined_75: Off20 additional info: OffProceed to Check List 1: Aus Citizen: OffPass: OffVisa: Offundefined_76: OffTrans: OffAcademic report: OffBaptism1: Offundefined_76a: Offlegal: Offundefined_77: OffNAPLAN: OffLegal related: OffRELATIONSHIP to Student: RELATIONSHIP to Student_2: Date Signed 1: Date Signed 2: Reference: OffSupporting: Offname_parent_1: name_parent_2: