little stars learners Application Form

Out of Home Care Application

Young Person's Details

Young Person's Full Name

Address where young person will reside during program and receiving their weekly mentoring sessions

Date of Birth

Current Year of School

Current Order (please attach a copy)

Short Term

Long Term

Is the child in the process of being reunified?

Yes

Expected date of reunification

Current contact arrangements with biological parents
Days

Supervised/ Unsupervised

Supervised

Unsupervised

Not applicable

Does the child identify as Aboriginal or Torres Strait Islander?

Yes

Is the child seeing a therapist?

Yes

Name

Center

Contact

Is the young person currently receiving any additional help through speech pathology/occupational therapy

Yes

Please provide details

Funding - Please only complete the application if you have confirmed funding.

How will this child be funded?

Complex Support Needs Allowance (CSNA)

High Support Needs Allowance (HSNA)

Department of Child Safety (child related costs)

Foster Agency

How is funding going to be provided for the program?

Foster Agency or other Organisation

CYJMA

Complex Support Needs Allowance

High Support Needs Allowance

Privately funded by Carer

Please select the session length you would like for weekly sessions with an Education Support Mentor:

1hr

1.5hr

2hr

Invoicing Options

There are four different payment options available. Please select your preferred option:

UPFRONT PAYMENT: Invoiced for the full 12-month program upfront (payment due 05/01/24)

SPLIT PAYMENT: Payment - Invoiced in 2 equal amounts (first payment due in this financial year (05/01/24) and second payment due in next financial year (due 05/07/24)

TERM PAYMENTS: Invoiced in 4 equal amounts (payment required prior to commencement of each term)

CSNA/HSNA - Fortnightly direct debit arrangements set up with the Carer upon additional documentation being signed by CYJMA

Details for invoice:

Company Name

Position

Individual Name

Address

Phone

Details of Person Completing Form

Name (form completer)

Role

Organisation Name

Office Address

Phone

Foster Carer / Kinship Carer / Guardian's Details

Carer Name

Address

Phone Numbers

Biological siblings living with child

Other siblings living in household

General Medical & Care Information

Does the child have a confirmed learning diagnosis or other?

Yes

Any pre-existing physical injuries/illnesses/ailments?

Yes

Please provide a description

Are there any physical, social or psychological issues that may affect the child's participation?

Yes

Please provide a description

Triggers which may impact upon the child's behaviour, psychological or emotional state (e.g. does the child respond better to males or females)

Yes

Please provide a description

Education and Learning Status

School child has attended for the past 2 years
School Name

Suburb

School the child is attending in 2024
School Name

Suburb

Is the child currently enjoying school? Please set out any difficulties the child is currently having.

Please include details of any diagnosed learning difficulties

Would you like the mentoring sessions to be online or in-person sessions?

Online

In-person

Academic Tutoring Commitment

Has the child had tutoring or educational support previously?

Yes

Can you make the child available for mentoring for at least 1 hour per week for 4 school terms (36 weeks)?

Yes

Are you able to make someone available to supervise the weekly mentoring sessions?

Yes

If your application for mentoring is accepted, the foster or kinship carer or guardian will be required to sign terms and conditions with Little Stars Kids and will also need to comply with any terms the mentoring company has in place. Are you agreeable to this?

Yes

Are you agreeable to the child participating in a research study to assess the impact of the mentoring on the child, as part of the broader study on the impact of education support for foster children in primary school years? (Please note that consent from the CYJMA will also be obtained)

Yes

Please select days available & then write suitable times for sessions in the box below

Please list suitable times here for the days you have selected above

Please note that this information will be used to source a education support mentor in early January. If there are any changes to availability, it is critical that you advise us prior to 5 January 2024. Any changes advised after this date may delay the commencement of tutoring.

Please select the areas which you would like the child to receive support in

Math

English

Both

Please provide details as to specific challenges the young person is facing with their education and/or schooling.

Please provide details as to why you believe the child would benefit from education support mentoring

How did you hear about the Little Stars Learners program?

Agency and Department Details

Please note that emails are required as weekly Session Summaries will be sent to all stakeholders. Please advise us if these details change at any time.

FOSTER AGENCY
Office Address

Agency Name

Contact Person

Phone

Session summaries will be sent to the child's carer, foster agency contact & CSO. Is there a teacher or other person whom you would like to also receive a copy of weekly summary?

Yes

Name

Position

CHILD SAFETY OFFICE
Service Centre Address: (e.g. Beenleigh Child Safety)

Contact Name

Phone

Consent

By signing this document, you agree that you have completed this truthfully and to the best of your knowledge. I consent to Little Stars Kids Pty Ltd ABN 48 602 704 781 (LSK) collecting the personal information on this Application Form for the purposes of assessing the application for funding I am authorised to provide this consent on behalf of the Child referred to in the application.

Carer/Guardian Name

Date

Collection Notice

Little Stars Learners collects the information on the Application Form for the purposes of considering whether to provide funding for tutoring services and for the evaluation of our programs efficacy. If you do not provide all of the requested information, we may not be able to properly assess the application. If your application is successful and you choose to enter into a Education Support Funding Agreement with us, we only disclose personal information with consent, or where we are required by law to do so. Our privacy policy is available at www.littlestarskids.org.au. It contains information about how you may access your personal information and seek correction of information. The privacy policy also contains information about how you can complain about a breach of privacy. Little Stars Learners does not disclose information overseas.

Attachments

Please attached the following documents to this application before sending.

Current Orders

Maximum file size: 10MB

School reports for the last 12 months

Maximum file size: 10MB

Relevant reports from psychologists, speech pathologists or other relevant experts

Maximum file size: 10MB

If you are human, leave this field blank.

little stars learners Application Form

Young Person's Details

Funding - Please only complete the application if you have confirmed funding.

Details for invoice:

Details of Person Completing Form

Foster Carer / Kinship Carer / Guardian's Details

General Medical & Care Information

Education and Learning Status

Academic Tutoring Commitment

Agency and Department Details

Consent

Collection Notice

Attachments

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