Prime Intervention_Student Registration Form

Student Name *

First Name Middle Name Last Name

Students Birth Date *

Day Month Year

School Name *

Current Year Level *

English Main Language at Home?

Yes No

If no, please specify...

Parents/Carers Name *

First Name Last Name

Relationship to Student *

Parents/Carers Contact Number *

Primary Email Address for Contact *

Address *

Emergency Contact *

First Name Last Name

Phone Number

Area Code Phone Number

Additional Parents/Carers Name *

First Name Last Name

Relationship to Student

Secondary Contact Phone Number *

Secondary Email Contact

Email to send Invoice to *

Areas of Concern *

English Math Both Math and English

Which Prime Intervention Centre do you wish to attend?

Ellenbrook Joondalup

Please provide us with your preferred days and times to assist with our scheduling. Please note that we cannot always guarantee your preference as this depends on our availability and therapist we find suitable for your child.

Please provide us with any further details on the areas of concern.

Please provide any information or previous diagnosis of learning difficulties.

Has your child ever been referred for extra services – Child Development Center, OT, Speech, for example?

Does your child wear glasses?

Yes No

Is your child currently taking any medication. If so, please specify.

Does your child have any allergies? If so please specify.

Does your child currently have an IEP, or individualised learning goals at school?

Yes No Unsure

Are you claiming through NDIS?

Yes No

Please upload a copy of your child's NDIS plan if available.

Browse Files

Special Family Circumstances (NB - We require copies of court orders for legal reasons.)

Includes single parent, dual custody, foster care, court orders, access restrictions, etc. Please provide details of the circumstances.

ADDITIONAL CONSENTS

Consent for publication of a student's Photo/Work

*

Yes No

*

	Photo Yes	Photo No	Work Yes	Work No
For Parents
Social Media
Centre Newsletter
Centre Website

Term Times

Our terms will run with the public-school system, except for term one when we start week two.

If your school is different from the public system you are still required to attend when the public system runs.

You are not required to attend and will not be charged for public holidays; however, your child is still expected to attend if their session is on a pupil free day.

Term Fees

We operate under a term-to-term contract. You will receive an invoice for the term (or part thereof) and are liable for the full amount.

As a courtesy, we allow various options for payment: upfront, weekly and part term

We reserve the right to discontinue tuition if no payments have been made by the halfway point of term and the full amount must be cleared a week before the end of term. If the full amount has not been received your enrolment will automatically cease for the subsequent term, unless you make contact to arrange a payment plan before the end of the current term.

If the choice is to pay weekly, understand that this does not negate the fact that this is a term contract and missed lessons are still payable.

Overdue amounts may incur weekly $25 late fees, and debt collection costs added.

If fees are to be split between two parties, we will need an agreement to pay from both parties before commencing tuition. The original party who signed the student up will be held responsible for the invoice if the other party refuses to pay.

Do you acknowledge you are signing up for a term, and as such are liable (even if the other partner refuses to pay) for the fees of a full term/or part there of? *

Yes No

Student Absences

Absences that are the result of sickness ( a doctor’s note must be provided ) can be made up on another occasion ( maximum of two occasions ) if enough notice is given, and only within the term the lesson is missed.
NB - Please initial if you acknowledge that two make up sessions ONLY are offered for sickness, and a doctor’s note must be given, and always ONLY at the discretion of the director.

Do you understand that only 2 make up sessions are offered for illness, extenuating circumstances and assembly, where enough notice is given and always ONLY at the discretion of the director. It is parent responsibility to make contact to request make up lessons. Request for make up lessons left until the last 2 weeks of term may result in a refusal. *

Yes No

Online Lessons

All resources provided for lessons and homework remain the property of Prime Intervention.
These are not to be reproduced, shared or distributed in any way.

NB - Please initial if you acknowledge you will not reproduce share or distribute any resources provided by Prime Intervention. *

Yes No

Staff Absences

On occasion staff are absent because of sickness or professional development. We will endeavour to arrange a relief member of staff, or pair your child up with another, just for that session.

If a relief or suitable pair is not available, we will arrange a makeup session (not part of your two allowed) or provide a credit towards your next term’s fees.

We endeavour to keep your child with the same tutor each week; however, in certain circumstances, tutors may be re-assigned as we find the best match for your child.
Tutor allocation remains at the discretion of the director.

Lockdown

Lockdown that occurs mid-term cannot be foreseen. Should this occur, depending on the length of the lockdown, we will either offer makeup lessons or credit towards lessons once the lockdown has ended. We will not offer refunds.

Changes of Tutor/Teacher

It may be necessary to change your child's tutor or teacher from time to time.
Tutors & teachers move on for study or full-time work. We always endeavour to place your child with the best possible available.
Students may need to move to different tutors or teachers that specialise in different areas of learning. This can happen if your child improves and or conversely other areas of need are discovered that need a different focus.

Assessment

All new students (or students returning after a significant break) will be assessed in order for us to plan your child's specific program. An initial assessments cost $75 and will include a verbal explanation. A formal, comprehensive assessment including a comprehensive written report will be available at your request for $200. The therapist will show and discuss with you your child’s results and you will receive an email detailing your child’s results and areas of need. The assessment itself remains the property of Prime Intervention.

If you require further formal, comprehensive reports throughout the term, these will be available for $200.

We conduct bi-annual reassessments, to track your child’s progress and to align their future program with their current needs. These assessments are carried out for no extra cost and include a summary of the results.

NB - Please nominate which Assessment you would like:

Initial Assessment with a verbal explanation $75 Initial Assessment with a comprehensive written report $200

Parental Obligations

We will provide homework for your child each week, specifically focused on what was covered in their weekly lesson and aimed for student success, and should not take longer than 10 minutes. We insist on the completion of the homework.
We send resources home so your child can practice the skills learned in their program. It must be understood that the cost for replacement of any resources not returned will be added to your account.
Your child will also require a scrapbook or file to keep their work.

Will you provide a scrap book or file for your child and will you commit to seeing that your child’s homework is complete each week? *

Yes No

Vaccinations

Vaccinations are a requirement for enrolment in all Western Australian Schools. While we are not a school, we are aware that we have many children in our centre at once, and endeavour to reduce the risk of infections for our students. For this reason, all parents are required to advise whether their child/children are up to date with their immunizations.

If your child has not been immunised or is not up to date with their immunisations, you MUST advise us if/when they are sick , and we will discuss the options with you.

NB – Please initial if you acknowledge that you will alert us if your child is not immunised/up to date with immunisation, and advise us if/when they are sick to discuss alternative lesson options until they are well. *

Yes No

Bullying

• Bullying is unacceptable behaviour and will not be tolerated at Prime Intervention. We maintain the right to refuse lessons to any student, or entry to any parent who engages in bullying.

NB – Please initial if you acknowledge that you understand bullying will not be tolerated by anyone at Prime Intervention: *

Yes No

Please sign below to acknowledge your understanding and acceptance of our term and conditions. We assume if you continue with us at Prime Intervention that you agree with these terms and conditions. Please print a copy of this contract for your own reference. *

Clear

Terms and Conditions