Please complete the form below.(*)required field

These details are required to enable A&J STUDENTCARE SERVICES
to meet the needs of your child whilst studying in Australia.

All personal information provided by you remains CONFIDENTIAL
and conform with Privacy laws operating in Australia

1. STUDENT DETAILS:

TITLE :(Mr/Miss) (*)

FAMILY NAME: (*)

GIVEN NAME(S): (*)

DATE OF BIRTH: (*)

COUNTRY OF ORIGIN: (*)

PASSPORT NUMBER: (*)

eMAIL ADDRESS: (*)

Photo to Upload:(passport size photo only!)

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2. FATHER DETAILS:

FAMILY NAME: (*)

GIVEN NAME(S): (*)

ADDRESS: (*)

TELEPHONE (Home):(including country and area code) (*)

TELEPHONE (Work):(including country and area code)

MOBILE PHONE:(including country and area code) (*)

eMAIL: (*)

3. MOTHER DETAILS:

FAMILY NAME:

GIVEN NAME(S): (*)

ADDRESS: (*)

TELEPHONE (Home):(including country and area code) (*)

TELEPHONE (Work):(including country and area code)

MOBILE PHONE:(including country and area code) (*)

eMAIL: (*)

4. INSTITUTION/SCHOOL & COURSE DETAILS:

SCHOOL NAME:

ADDRESS: (*)

TELEPHONE: (*)

eMAIL: (*)

CONTACT PERSON: (*)

STUDENT ID NUMBER:

COURSE: (eg. ELICOS, Year level, Foundation, Bachelor of ) (*)

COMMENCEMENT DATE: (*)

5. OTHER INFORMATION:

HEALTH/MEDICAL CONDITIONS:

ANY OTHER INFORMATION YOU THINK WILL ASSIST US IN CARING FOR YOUR CHILD:

LANGUAGE SPOKEN: (*)

6. AGENT DETAILS:

COMPANY NAME: (*)

COMPANY STATUS: (eg. Head Office, Branch Office)

ADDRESS: (*)

COUNTRY: (*)

TELEPHONE:(including country and area code) (*)

eMAIL: (*)

CONTACT PERSON: (*)

7. DECLARATION:
I declare that the information given in this application is true and correct.

Yes (*)

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