ABORIGINAL HOSTELS LIMITED2017 Secondary Education

Student ApplicationNorthern Territory─Top End

Student name: (Name used onyour ABSTUDY application or at Centerlink)

Centrelink Reference Number:(if known)

Has the student been known by any other name ─ skin/clan/tribal name.

Nickname / Prefered name:

Please indicate which hostel you are applying for

Northern Territory Western Australia

Fordimail HostelKATHERINE

Wangkana Kari HostelTENNANT CREEK

Kardu Darrikardu NumidaWADEYE

Kununurra HostelKUNUNURRA

Lot 2014 Zimin Drive Cossak

Katherine NT 085008 8971 1404

fordimail@ahl.gov.au

Lot 782 Paterson Street Tennant Creek NT 0860

08 7905 8770 wkari.hostel@ahl.gov.au

Nilinh RoadWadeye NT 0822

08 8978 1210 wadeye.hostel@ahl.gov.au

Lot 302 on DP 44064 Victorian Highway

Kununurra WA 6743 08 7904 0250

kununurra@ahl.gov.au

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Contents of ApplicationThis application form requests important information that must be completed in order for a student to be considered for enrolment at Aboriginal Hostels Limited (AHL) secondary education hostels.

Who can Apply?Our secondary education hostels are for Aboriginal and Torres Strait Islander students of high school age who need to live away from home to obtain a secondary education.

Three ways to complete and submit this application form. 1. Print a blank application form then handwrite your responses. Post your completed application

to the hostel (address details listed below).2. Type your responses directly into the application form, then click ‘Print’. Post your completed

application to the hostel (address details listed below).3. Type your responses directly into the application form, then click the ‘Email Application’ button.

Need help?Should you need assistance in completing this application form, or have futher enquiries about enrolment, please contact the secondary education hostel on the contact details above.

When to complete this applicationPlease complete and submit this application by 1 December in order to be considered for term 1 of the 2017 school year. If you intend to apply after this date, please contact the AHL secondary education hostel directly (contact details above) to discuss availability and a timeframe to submit your application.

1. Enrolment information

School entry level for 2017: Year 7

Year 8

Year 9

Year 10

Year 11

Year 12

School that student will attend:

2. Student information

Surname:

First name:

Date of birth:

Home address:

Student mobile no:

Gender: Male Female Unspecified

Religion:

3. Parent/Guardian information

Full name:

Residential address:

Postal address:

Telephone No/s.:

Email:

Relationship to student: Mother Father Guardian

Full name:

Residential address:

Postal address:

Telephone No/s.:

Email:

Relationship to student: Mother Father Guardian

Who is the Primary Contact? Parent/Guardian 1

Parent/Guardian 2 Both

Par

ent/G

uard

ian

1P

aren

t/Gua

rdia

n 2

Secondary Education Student Applicationpage 2

7. Emergency contact (if primary contact unavailable)

Name: Phone number:

Relationship to Student:

5. Medical conditions

Does the student have or had any medical condition that AHL would need to be aware of ?

Yes No

If yes please provide details below:

6. Dietary needs

Does the student have any special dietary needs ?

Yes No

If yes please provide details below:

4. Siblings

Are there any brothers/sisters currently attending AHL secondary education hostels.?

Yes No

If yes please provide details below:

Name: Years attended:

Name: Years attended:

Secondary Education Student Applicationpage 3

Please provide a short statement for question 5 and 6. You will be asked to supply a more detailed responce when you fill out the ‘Student Medical Information’ form.

8. Student school/hostel history (if you require more room to answer, continue on the next page)

1

Has the student attended a AHL Secondary Education hostel in the past? (If yes please provide the name of the hostel and what year they attended)

Yes No

2

Please provide details of any extended absence history from school like illness, relocating to a new town, cultural reasons etc.

3

Please provide details of any special support, disability or extra tuition the student has received during the past two years.

4

Please outline any activities in which the student has special skills or interests. (social, sport, hobbies, recreational)

5

Has the student ever run away from school, been a truant or have a criminal record? (If yes provide details)

Yes No

6

Please provide details the student’s current school and years that they attended.

Permission to access information from applicant’s school

I consent for information to be provided to AHL from the student’s current school in order to assess eligibility for the student’s application. I understand that this information will only be used for this purpose to identify specific support requirements. Information obtained may include student’s conduct, has the student been or currently on suspension, and comments about academic ability and achievements.

I agree that AHL can access this information (tick box) Date:

Signature of Parent or Guardian: If you submit electronically please tick the box

Secondary Education Student Applicationpage 4

page 5

9. Extra information from previous page, or other information about the studentyou would like to tell us.

Secondary Education Student Application

Hostel Aims and Rules

On commencement of hostel life, students undergo an induction, introducing them to the hostel and providing detailed information about the rules by which the Hostel operates. View Hostel Rules.

10. Declaration

By ticking the box you declare that all information provided in this application is to my knowledge is true and correct.

Parent or Guardian Name:

Signature of Parent or Guardian: If you submit electronically please tick the box

Date:

Privacy Statement

For information on our Privacy Policy and how your information is stored securely to protect against loss, misuse, unathorised access or disclosure, please view AHL’s Privacy Statement.