Young Person's Details
Young Person's Full Name
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Address where young person will reside during the 2025 program and receive their weekly learning sessions
*
Residential Address
*
Date of Birth
*
Current Year of School
*
Name of School (if applicable)
Current Hours (if part time)
Details of Person Completing Form
Name (form completer)
*
Role
*
Organisation Name
Office Address
Phone
*
Email
*
Carer Name
*
Address
*
Email
*
Phone Numbers
*
Phone Numbers
Biological siblings living with young person
Other siblings living in household
Foster Agency Details
Office Address
*
Agency Name
*
Contact Person
*
Phone
*
Email
*
Name
*
Position (e.g. teacher, occupational therapist)
*
Organisation/School
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Email
*
Phone
*
Child Safety Details
Service Centre Address (e.g. Beenleigh Child Safety)
*
Child Safety Officer Name
*
Phone
*
Email
*
Funding
Details for Invoice
Company Name
*
Position
*
Individual Name
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Address
*
Email
*
Phone
*
Learning Support Sessions
If yes, please set out details
If yes, please state the name of the young person’s current Learning Support Mentor
How many years has the student been part of the Little Stars Learners Program?
Please list suitable times here for the days you have selected above
*
Please note that this information will be used to match a Learning Support Mentor with the young person in early January. If there are any changes to availability, it is critical that you advise us prior to 10 January 2025. Any changes advised after this date may delay the commencement of Learning Support Sessions.
Please provide details as to specific challenges the young person is facing with their education and/or schooling.
*
Please provide details as to why you believe the young person would benefit from learning support.
*
How did you hear about the Little Stars Learners program?
*
Current Support Details for Young Person
If yes, expected date of reunification
Current contact arrangements with biological parents (days)
If yes, please complete:
Name
Centre
Contact
If yes, please provide details
Please specify if you selected "Other"
Please provide a description
If yes, please provide a description
If yes, please provide a description
Is the young person currently enjoying school? Please set out any difficulties the young person is currently having.
*
Carer/Guardian Name
*
Date
If you are human, leave this field blank.