Last updated: 27-Jan-05
page 6
version 1.1
No. & Street or Box No.:
Suburb:
State:
Postcode:
Telephone Number
Fax Number
Does the primary family have a current Ambulance Subscription: (tick)
Yes
No
Medicare Number:
PRIMARY FAMILY BILLING ADDRESS:
Write “As Above” if the same as Family Home Address
No. & Street
Suburb:
State:
Postcode:
OTHER PRIMARY FAMILY DETAILS
Parent
Step-Parent
Adoptive Parent
Foster Parent
Host Family
Relative
Relationship of Adult A to Student: (tick one)
Friend
Self
Other
Parent
Step-Parent
Adoptive Parent
Foster Parent
Host Family
Relative
Relationship of Adult B to Student: (tick one)
Friend
Self
Other
The student lives with the Primary Family: (tick one)
Always
Mostly
Balanced
Occasionally
Never
Send Correspondence addressed to: (tick one)
Adult A
Adult B
Both Adults
Neither
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