Please complete the form below.

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

(*)required field

1. STUDENT DETAILS:

TITLE :(Mr/Miss) (*)

FAMILY NAME: (*)

GIVEN NAME(S): (*)

DATE OF BIRTH: (*)

COUNTRY OF ORIGIN: (*)

PASSPORT NUMBER: (*)

E-MAIL: (*)

Photo to Upload:(passport size photo only!)

Acceptable file types: gif,jpg,jpeg,png,bmp.
Maximum file size: 1mb.

2. PARENT: FATHER'S

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)

E-MAIL: (*)

3. PARENT: MOTHER'S

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)

E-MAIL:

4. INSTITUTION/SCHOOL INFORMATION

SCHOOL NAME: (*)

ADDRESS: (*)

TELEPHONE: (*)

E-MAIL (*)

CONTACT PERSON:

STUDENT ID NUMBER: (*)

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

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 INFORMATION
(Agent please complete this section)

COMPANY NAME:

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

ADDRESS:

COUNTRY:

TELEPHONE:(including country and area code)

MOBILE PHONE:(including country and area code)

E-MAIL:

CONTACT PERSON:

7. DECLARATION

I declare that the information I provide in this form is correct and I agree for this information to be used by A&J Student Care Services as requried.

YES (*)

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