Referral Form | The Pavilion School

Referral Form

If you wish to discuss the referral please phone on 9404 8800, Monday to Friday 9am - 12pm, you can also return the referral by fax number 9409 9868 or email gleeson.joanne.n@edumail.vic.gov.au

Referral Details

Date of Referral
Referring Persons Name
Agency (If Applicable)
Phone
E-mail

Student Details

Name
Date of Birth
Phone Number
Mobile
Address

Parent / Carer / Contact Person

Name
Phone Number
Mobile
Relationship

Educational History

Approximate Date Last Attended School
School last attended #1
School last attended #2
Year Level
Brief Reason for Disengagement

Key Agency Involvement (If Applicable)

Agency Name
Worker Name / Title
Phone Number
Mobile
E-mail
DHS Involvement (Protective / Youth Justice)?

Student and or Parent / Guardian Approval

I understand that the information on this referral form may only be used for enrolment purposes by Pavilion staff unless otherwise authorised
Name of student
Student check box to approve
Name of Parent / Guardian
Parent / Guardian check box to approve
If you wish to discuss the referral please phone on 9404 8800, Monday to Friday 9am-12pm and return or return referral to fax number 9409 9868 or email to gleeson.joanne.n@edumail..vic.gov.au

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