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APPLICATION FOR HIGH SCHOOL PROGRAMMES AT THE UNIVERSITY OF WESTERN AUSTRALIA

(for Aboriginal & Torres Strait Islander People)

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SCHOOL OF INDIGENOUS STUDIES

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CENTRE FOR ABORIGINAL MEDICAL & DENTAL HEALTH

University of Western Australia School of Indigenous StudiesShenton House M30335 Stirling HighwayCrawley WA 6009Tel: 08 6488 3428/ 1800 819 292Fax: 08 6488 1100www.sis.uwa.edu.auCRISCOS Provider Code: 00126G

Please tick the box below indicating the activity for which you wish to be enrolled:

HEALTH CAREERS WORKSHOP (YEAR 10)

INDIGENOUS SCIENCE CAMP (YEAR 9)

YEAR 12 SEMINAR

TEE REVISION COURSES YEAR 12 YEAR 11

CAMPUS CHALLENGE (YEAR 10 – 12)

PERSONAL DETAILSMr/Ms/Miss/Mrs etc. Family Name: First Name:

Date of Birth: Shirt Size:

Term Address: ie your address if you are living away from home to attend school, (eg boarding)

Suburb/Postcode:

Home Address: If same as term address write A/A

Suburb/Postcode:

Westrail Concession Number (if applicable) Home Phone: Fax:

Email: Mobile:

School: School Phone: School Fax:

School Address:

School Contact: Position at School:

Email: Phone:

EDUCATION BACKGROUNDPlease tick any of the boxes below indicating what you have done at school. Give details where relevant

(i) Year of study

(ii) What subjects are you currently studying?

Complete only if studying in Year 12:

(iii) Are you studying any TEE Subjects? No Yes If yes please list subjects studied:

(iv) What tertiary aspirations do you have?

(v) Are there any particular study areas, courses you would like information on or would like to visit during the camp, workshop? (eg. Medicine, Human Movement, Science, Social Work, Dentistry, Psychology, Physiotherapy)

School Report Attached Yes No Date to be sent/faxed

Student ID (official use only)

EMERGENCY OR FAMILY CONTACT (during Seminar/Camp/Workshop)Name:Address:Relationship:Contact Telephone Numbers – Home: Work: Mobile:

CHECKLISTIS THE APPLICATION COMPLETE? Have you enclosed and/or completed:• Your application form• Parents/guardian consent form • Essay• Copy of last school report

ESSAYPlease write a short essay on the two questions below:

Question 1 Give reasons why you want to attend the Camp/Seminar/Workshop?

Question 2 How do you think you will benefit from attending the Camp/Seminar/Workshop?

Please return this completed application to: THE SCHOOL OF INDIGENOUS STUDIES SHENTON HOUSE M303THE UNIVERSITY OF WESTERN AUSTRALIA 35 STIRLING HIGHWAY CRAWLEY WA 6009 Any queries, contact: 08 6488 3847 toll free: 1800 819 292 or sis@sis.uwa.edu.au

PARENT/STUDENT TRAVEL AND PHOTO CONSENT FORM

I hereby consent to the attendance of my son/daughter, to

attend the arranged by The University of Western Australia

and his/her travel by coach, rail or air if necessary. I understand that I am responsible for the full cost of any

travel cancellations on our behalf.

I authorise the staff in charge of the Camp/Seminar/Workshop to photograph my child during the workshop activities

as required for the sole purpose of promotional material for The University of Western Australia.

I authorise the staff in charge of the Camp/Seminar/Workshop to monitor my child's behaviour during the week. In

particular I authorise the staff to carry out any action necessary to ensure compliance with the law and the protection

of other children including, if necessary, removing my child from the Camp/Seminar/Workshop.

* Drugs and alcohol are strictly prohibited at the Camp/Seminar/Workshop. Students found in possession will be immediately sent home and parent/guardian contacted.

Signed: Signed: Parent/Guardian Student

Name printed: Name printed:

Date: Date:

MEDICARE CARD Number:

EXPIRY DATE:

Please provide:

(a) Details of any medical attention your child will need or any medications your child will need to take during the Camp/Seminar/Workshop (if not applicable write n/a).

(b) Details of allergies or any other condition that may require attention during the Camp/Seminar/Workshop and the treatment required (if not applicable write n/a).

Please return ASAP to:

Brendon DeGois Phone: 08 6488 3847School of Indigenous Studies M303 Free call: 1800 819 292The University of Western Australia Fax: 08 6488 110035 Stirling Hwy E-mail: Brendon.DeGois@uwa.edu.auCRAWLEY WA 6009

• Please Note: You must complete all of the above to be considered for Camp/Seminar/Workshop.