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Child’s Full Name*

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School Contact Details

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My child’s school has been notified of his/her medical condition

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Permission to contact child's school*

I give permission for a representative of the Back on Track WA program to contact my child’s school to establish a working relationship with:

Working relationship permission

Principal

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Permission to consult with SSEN*

I give my permission for a representative of the Back on Track WA program to consult with SSEN:M&MH (School of Special Educational Needs: Medical & Mental Health) to establish a working relationship to support my child.

Permission to external reporting*

I understand what the Back on Track WA program involves after discussion with the Education Advocate and give my permission for unidentified data to be used in reporting to external agencies e.g. donors.

Educational Priorities/Concerns

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