Mobile number Email address Current residential address Street no. Street no. Street name Street name Suburb/town Suburb/town State Postcode State Postcode Postal address if the same as (write ‘as above’ residential address) Suburb/town Suburb/town State Postcode State Postcode Occupation Employer details Business name Business name Business residential address Business residential address Employer contact number Employer contact number SECTION 2 DETAILS OF STUDENT(S) FOR WHOM BENEFITS ARE BEING SOUGHT – STUDENT DETAILS 1ST 2ND 3RD 4TH 5TH (Tick boxes where appropriate) STUDENT STUDENT STUDENT STUDENT STUDENT Family name (as on birth certificate) Given name Sex of student Date of birth / / / / / / / / / / Year or grade enrolled this year E.g. year 1 Name and address of school/institution attending this year (if studying by correspondence give details of school supervising lessons) Level of study pre-school, transition, – primary, middle or senior. Is the student receiving Assistance for Isolated Children (AIC)? Please provide a copy of AIC Distance – Education statement
Mobile number Email address Current residential address Street no. Street no. Street name Street name Suburb/town Suburb/town State Postcode State Postcode Postal address (write ‘as above’ if the same as residential address) Suburb/town Suburb/town State Postcode State Postcode Occupation Employer details Business name Business name Business residential address Business residential address Employer contact number Employer contact number SECTION 2 – DETAILS OF STUDENT(S) FOR WHOM BENEFITS ARE BEING SOUGHT STUDENT DETAILS (Tick boxes where appropriate) 1ST STUDENT 2ND STUDENT 3RD STUDENT 4TH STUDENT 5TH STUDENT Family name (as on birth certificate) Given name Sex of student Date of birth / / / / / / / / / / Year or grade enrolled this year E.g. year 1 Name and address of school/institution attending this year (if studying by correspondence give details of school supervising lessons) Level of study – pre-school, transition, primary, middle or senior. Is the student receiving Assistance for Isolated Children (AIC)? Please provide a copy of AIC – Distance Education statement
student-assistance-schemes-application-form.docx