Insert
School Lo
ADDITIONAL CONTACT PERSON FORM
Additional Contact Person’s Details
Additional Contact Person Details in the context of this form refers to any person nominated by the Parent/Legal Guardian on the
basis of having financial responsibility, providing some degree of care or acting as an emergency contact for the student.
Student Details
Legal Surname:
Legal First Name:
BCE Student ID (if known):
Date of Birth:
S __ __
D D / M M / Y Y Y Y
School Name:
__ __ __ __
School Suburb
Additional Contact Person’s Details
Legal Surname:
Title:
Mr
Ms
Sr
Mrs
Dr
Br
Gender:
Male
Miss
Fr
Rev
Preferred Surname:
Prof Legal First Name:
Preferred First Name:
Other Given Name(s):
Female
Date of Birth:
D D / M M / Y Y Y
Residential Address
Postal/Correspondence Address
Same as Residential address
Same as Parent/Legal Guardian/Caregiver 1
Same as Parent/Legal Guardian/Caregiver 2
Billing Address (if required)
Same as Residential address
Same as Postal/Correspondence Address
Street Address:
Postal Address:
Postal Address:
Suburb/Town:
Suburb/Town:
Suburb/Town:
State:
Postcode:
State:
Country (if not Australia):
Contact Method Type
Home Telephone Number:
(
Postcode:
State:
Country (if not Australia):
Order
Silent
Indicate best
contact order
Is this
number
silent?
Country (if not Australia):
Contact Method Type
Work Telephone Number:
(
)
)
Mobile Telephone Number:
Work Mobile Telephone Number:
Email Address:
Work Email Address:
Email may be used for billing purposes
Yes
No
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Postcode:
Order
Indicate best
contact order
Silent
Is this
number
silent?
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What is the relationship of this person to the student? (Tick one (1) only
Mother
Father
Step Mother
Step Father
Foster Mother
Foster Father
Grandmother
Grandfather
Home Stay Parent
Home Stay Sister
Home Stay Brother
Sister
Brother
Dentist
Legal Guardian (for Dept. of
Half Sister
Half Brother
Step Sister
Step Brother
Foster Sister
Care Provider
Counsellor/Social Worker
Agent
Reg. Exchange Org
Foster Brother
Communities only)
Aunt
Uncle
Niece
Nephew
Cousin
Friend
Doctor
Is this person to receive any of the following
forms of Communication?
Does this person perform any of the following
roles in regards to the student?
Report Cards/Progress Reports:
Yes
Emergency Contact:
Yes. Indicate the priority in which this person
No
Newsletters:
Yes
is to be contacted (e.g. 1st, 2nd, 3rd, 4th, etc.)
No
Invitations:
No
Yes
Legal Guardian:
If this person is not a birth or adoptive parent, then legal
documentation must be attached.
Yes
No
No
School Portal Access:
Yes
No
Does this person reside with the student?
Yes
Caregiver:
A person who has responsibility for the general wellbeing
of a student on a day-to-day basis.
Yes
No
Does this person require the assistance of an
interpreter?
Yes
No
No
I/We have signed the BCE Collection Notice Form
SIGNATURE of Parent or Legal Guardian
SIGNATURE of Parent or Legal Guardian
PRINT NAME of Parent or Legal Guardian
PRINT NAME of Parent or Legal Guardian
RELATIONSHIP to Student
RELATIONSHIP to Student
DATE SIGNED
DATE SIGNED
D D / M M / Y Y Y Y
D D / M M / Y Y Y Y
Additional Contact Person Form V3: 20141101
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