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Student Record

STUDENT RECORD 20...

Student's Information

Student's Information*

First Last

Date of Birth*

Grade/Year*

Australian Citizen

Australian Citizen

Yes
No

Permanent Resident

Permanent Resident

Yes
No

Parent's Information

Parent’s (Guardian’s name)*

Telephone numbers:

Home*

Work

Mobile*

Email Address

Parent’s e-mail address*

Address

Address*

Street Address City ZIP / Postal Code

Emergency Contact if different from above

Emergency Contact if different from above*

Any specific medical factors affecting the child

Any specific medical factors affecting the child*

The name of the family doctor

The name of the family doctor

Phone number of the family doctor

Phone number of the family doctor

Permission to call ambulance in case of emergency

Permission to call ambulance in case of emergency*

Prices Per Term

Please choose below in which ordinal number the child was enrolled in Polish School Canberra.

Prices*

Please input HOW MANY TERMS (NOT PRICE) in the quantity field.

1st Child

1st Child

Price: $ 100.00

2nd Child

2nd Child

Price: $ 90.00

3rd Child

3rd Child

Price: $ 0.00

4th Child

4th Child

Price: $ 0.00

Total Amount

Total Amount

$ 0.00

Payment Options

Payment Options*

Cash (at school)
Bank Transfer
Credit or Debit Card

Simply come to the school, complete an enrolment form, together with the cash, and we can process your enrolment.

Here are our bank account details:

Bank: St George Bank
Account Name: The Polish Educational Committee
BSB: 112 908
Account Number: 153 397 125
If paying electronically please state "surname" and "term x" as a reference.

Credit Card

Card Details

Cardholder Name

Date

Date*

Comments

This field is for validation purposes and should be left unchanged.

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