Application for Part-time Attendance

Application for Part-time Attendance
(This application may be initiated by a parent/guardian/school/Learning Service/independent student.)
TO: THE GENERAL MANAGER LEARNING SERVICES OR DELEGATE
TODAY’S DATE: __________
LEARNING SERVICE: __________________________________________________________________________
SCHOOL: ______________________________________________BCN (School Number): __________________
STUDENT NAME: _________________________________________________ED-ID: ______________________
DoB: ___________ GRADE: ___________ ATSI STATUS: _________________ MALE / FEMALE (Please circle)
PARENT(S’)/ GUARDIAN NAME:____________________________________________TEL NO: ___________
ADDRESS: ____________________________________________________________________________________
STUDENT ADDRESS (If different): _______________________________________________________________
____________________________________________________________________TEL NO: __________________
This application was initiated by the: (TICK ONE BOX ONLY)
□ School/Learning Services
□ Parent/Guardian
□ Independent Student
Department of
Education
Total FTE that the student will be attending school: ____________________ (e.g. 0.5 FTE)
REASON FOR APPLICATION FOR PART-TIME ATTENDANCE
Please tick the primary reason from the list below
TICK ONE BOX ONLY
□ Employment – Apprenticeship
□ Employment – Traineeship
□ Employment – Other
□ Education – Other education
□ Education – Flexible provision
□ Defence Force commitments
□ Fulltime Carer
□ Illness/Incapacity
□ Family reasons
□ Other
Please provide a description of the primary reason and any other reasons for the application. (If the reason
for this application is student employment, documentation from the employer must be provided.)
Please provide verification from medical practitioner if the application is due to illness/incapacity.
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Doc ID: TASED-4-1857 1/3

PRINCIPAL REPORT
Please attach the Principal’s report, including details of action taken to provide for student's individual
educational development, and to retain in this school, as appropriate.
PRINCIPAL NAME: ___________________________________________________________________________
SIGNATURE: ____________________________________________________________ DATE: ________________
SOCIAL WORKER REPORT
Please attach the Social Worker report.
SOCIAL WORKER NAME: _____________________________________________________________________
SIGNATURE: ____________________________________________________________ DATE: ________________
DETAILS OF PART-TIME ATTENDANCE
START DATE: _________________________ TERM ( )
REVIEW DATE: _________________________ TERM ( )
END DATE*: _________________________ TERM ( )
(*The maximum period of part-time attendance without review, or the maximum period until a review is
required, is the shorter of either one term or until the end of the current term)
Please name participants in the review process, including parent/guardian and student (if appropriate):
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PARENT/GUARDIAN COMMENT or INDEPENDENT STUDENT COMMENT (if independent student
is applying for this exemption)
Please note: if the student is on Care and Protection Orders the guardian is most likely to be the Child
Protection Worker (not the foster carer)
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SIGNATURE: ____________________________________________________________ DATE: _______________
Doc ID: TASED-4-1857 2/3

GENERAL MANAGER LEARNING SERVICES - DECISION
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SIGNATURE: ____________________________________________________________ DATE: _______________
Doc ID: TASED-4-1857 3/3