Student Information Form

Student Information Form

New students
All new PEAC students are required to complete this form to confirm their acceptance into the program and advise PEAC staff of their relevant contact and medical details. The information is used and stored within Wheatbelt PEAC only. You can view more about our privacy policy here.

Online PEAC
If you cannot attend face-to-face classes and wish to be considered for online PEAC, please ensure you have completed the form below and then email us with your request and include your child’s name, school and date of birth.

Existing students
If you are an existing student and wish to make changes to the form, please email us with your child’s name, date of birth and updated details.

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Student Details

Student First Name(Required)

Student Preferred Name(Required)

Student Last Name(Required)

Date of Birth(Required)

Gender(Required)

Does the student identify as Aboriginal or Torres Strait Islander?(Required)

School(Required)

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Nearest PEAC Centre

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What year (date) was/will the student be in year 5

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Year

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Status

Home Address(Required)

Parent/Guardian 1 Contact Details

Parent/Guardian 1 Name(Required)

Parent/Guardian 1 Phone Number (mobile)(Required)

Parent/Guardian 1 Phone Number (home)

Parent/Guardian 1 Phone Number (work)

Parent/Guardian 1 Email Address(Required)

This will be used for PEAC communications only.

Do you want to add a second contact?(Required)

Parent/Guardian 2 Contact Details

Parent/Guardian 2 Name(Required)

Parent/Guardian 2 Phone Number (mobile)(Required)

Parent/Guardian 2 Phone Number (home)

Parent/Guardian 2 Phone Number (work)

Parent/Guardian 2 Email Address

This will be used for PEAC communications only. You may leave this blank if you do not want communications sent to this email.

Do you want to add an Emergency Contact?(Required)

Emergency Contact Details

Someone other than a parent/guardian

Emergency Contact Name(Required)

Emergency Contact Phone Number(Required)

Student Medical Details

Medical Conditions(Required)

Is your child subject to seizures, fainting, epilepsy, diabetes or any other condition that may affect his or her safety?

Medical Condition Details(Required)

Disability(Required)

Does your child have a disability?

Disability Details(Required)

If yes to the above question, please provide further details

Severe Allergies(Required)

Is your child severely allergic to anything such as penicillin, other drugs, foods, bites etc.?

Allergy Details

If yes to the above question, please provide further details

Student Health Care Plan(Required)

Does your child have a current Health Care Authorisation Plan at school?

Upload Student Health Care Plan

Please scan and upload the student's up to date Health Care Plan here, or if not currently available , email to Wheatbelt PEAC

Drop files here or

Max. file size: 128 MB.

Medication Prescribed(Required)

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).

Medication Details(Required)

Please state name of medication, dosage and frequency of use:

Medication Self-Administration(Required)

Does your child self-administer the medication?

Tetanus Vaccination Date

If known, what was the date of your child's last tetanus vaccination?

Name of Medical Practice:

Other Conditions or Needs

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).

Media Consent

Student's images and/or their work samples are often published to recognise excellence or effort and may appear 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 below. You are of course at liberty to withdraw your consent at any time by contacting PEAC administration by email.

PEAC website or any medium in relation to PEAC related activities.
Promotional material for the Department of Education or PEAC.
Educational articles for local and community newspapers.

Media Consent(Required)

Internet Access Permission

Student access to the internet is provided in accordance with school policy for use of technology in PEAC courses. Student access is contingent on abiding by the 'PEAC Student Computer & Internet User Agreement'.

Internet Access Permission(Required)

Student Computer and Internet User Agreement

I agree to follow the PEAC online rules set out below when I use the computer, internet or a log-on account for PEAC work at a PEAC Centre or at home.

Communicating with Clarity and Precision while Taking Responsible Risks

I will ask the teacher before accessing PEAC computers
It is my responsibility to inform the teacher immediately if I encounter any problems

Managing Impulsivity

I will keep a record of any login details (username and password) and not share them with others
I will not give out my name, phone number, address, name of the school, photographs or other details about myself or others to any online medium without checking with the teacher first
I will take care when using the computer equipment and will not change any computer settings or access other students’ folders
I will not use the computers to be mean, rude or unkind to other people

Thinking about your Thinking

If I download work or pictures from the Internet I will acknowledge where it came from
I know that I am responsible for my own online behaviour
I know that PEAC and the Department of Education is able to see anything I access online or email
I know that I am responsible for any thumb drives or devices that are used in class

I understand that

The misuse of online services will result in consequences and communication to my parents and home-school

I agree to abide by the acceptable usage agreement for PEAC students.

I understand that if I break any of the rules in the agreement; it may result in disciplinary action.

Transport

Travel Agreement(Required)

I am responsible for the safe and legal transport of my child to and from PEAC courses and venues. There must be a handover of responsibility for the child between the transport provider and the PEAC teacher. Students are to arrive no earlier than 10 minutes prior to the commencement of the course session and are to be collected no later than 10 minutes after the session has been completed.

I agree to the above statement

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PEAC Online

Wheatbelt PEAC provides an online learning option for students who are unable to attend their closest PEAC centre. It should be noted that online PEAC is, understandably, a different learning experience to face-to-face courses. See our Moodle Information page for more details.

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PEAC Online Preference(Required)

Please indicate your preference for your child to attend PEAC either at a PEAC centre or online. This information will assist us to plan courses. You are welcome to change this at any time.

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Student Details

Parent/Guardian 1 Contact Details

Parent/Guardian 2 Contact Details

Emergency Contact Details

Student Medical Details

Media Consent

Internet Access Permission

Transport

PEAC Online

PEAC Administration