BILC Enrollment Form

Are you a new or returning student?
New StudentReturning Student

Student Information

Personal information about the student enrolling

Full Name *

Date of Birth *

Gender *
---MaleFemale

Address

Street Address *
Street Address Line 2
Suburb *
State *
---VICNSWNTSAWATASOLDACT
Post Code *

Name of Academic School *
Academic Year/Grade *

Medical Conditions

Do you have any diagnosed medical conditions? *
Do you have any special dietary requirements? *
Medicare Number *

Parent / Guardian / Next of Kin Details (1)

Information about a parent/guardian/next of kin for the student (must be aged 18 years and older)
Full Name *
Relationship to student *
Mobile Number *
Phone Number
Email *

Address

Street Address *
Street Address Line 2
Suburb *
State *
---VICNSWNTSAWATASOLDACT
Post Code *

Parent / Guardian / Next of Kin Details (2)

Information about a parent/guardian/next of kin for the student (must be aged 18 years and older)
Full Name *
Relationship to student *
Mobile Number *
Phone Number
Email *

Address

Street Address *
Street Address Line 2
Suburb *
State *
---VICNSWNTSAWATASOLDACT
Post Code *

Photography & Film Permission

The School may take photos/videos of students for purposes of documentation, assessment and marketing. These images may be used for print, online and social media activities. The student’s image will only be used after a formal written consent has been obtained from the parents/guardians

Photography & Filming Permission * ---Yes, I give consent for photos/videosNo, I do not give consent for photos/videos

Declaration

I agree that the above information is correct and I will inform Ballarat Islamic School if there are
any changes to above mentioned details

To be completed by a parent / legal guardian *
I agree that the above information is correct

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