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Ct Person School Address Ph (08) DECS form ED258 Suburb/town P/code Fax (08) Email Mobile website Section A: Student Details School Use Student is to complete all boxes in this section, carefully note the declaration below, then sign and date it. Family Name Date Submitted Year Level Given Name Birth Date Student s Emergency Contact Name: (Parent / Caregiver / Other) Address: Phone: Form Check Home Work Mobile Any special medical condition, medication or disability that m.

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