DIRETTORAT GĦAL SERVIZZI EDUKATTIVI DIRECTORATE FOR EDUCATIONAL SERVICES DIPARTIMENT SERVIZZI GĦALL-ISTUDENT STUDENT SERVICES DEPARTMENT SETTUR EDUKAZZJONI SPEĊJALI SPECIAL EDUCATION SECTOR TRIQ FRA GAETANO PACE FORNO, FRA GAETANO PACE FORNO STREET, ĦAMRUN HMR 1100 HAMRUN HMR 1100
TEL: 21228349 / 50 MALTA
SERVICE FOR THE VISUALLY IMPAIRED – REFERRAL / INFO FORM
STUDENT’S NAME: D.O.B. I.D.
NAME OF FATHER ADDRESS:
MOTHER
LEGAL GUARDIAN POST CODE
TEL: MOB.
CONDITION:
VISUAL ACUITY
(ATTACH OPHTHALMIC REPORT)
CASE ADDRESS: REFERRED BY :
GRADE / PROFESSION :
SIGNATURE : EMAIL ADDRESS:
SCHOOL DATE : TEL: FAX: RUBBER STAMP
CLASS: KG YEAR FORM USES ANY OTHER EDUCATIONAL SERVICES OR ATTENDS ANY OTHER N.G.O.?
YES NO IF YES, LIST EDUCATIONAL AND N.G.O. SERVICES. ATTENDS C.D.A.U. YES NO
STATEMENTED YES NO
STM NO. DATED:
L.S.A. SUPPORT YES NO
TYPE OF L.S.A. SUPPORT:
FOR OFFICE USE: APPROVED BY (NAME): MEDICAL CERTIFICATES GRADE/PROFESSION : OPHTHALMOLOGIST’S REPORT DATE: SIGNATURE: OTHER REPORTS SCHOOL VISIT HOME VISIT SECTOR VISIT CONSENT FORM
STUDENT CASE PASSED ON TO: (TEACHER'S NAME) SERVICE INTERRUPTED ON: SERVICE ENDED ON:
REASON : REASON:
DATE: SERVICE RESUMED ON:
REMARKS:
N.B. Parents / Legal guardian are to fill the STATEMENT OF CONSENT FORM Please attach all ophthalmic certificates, reports and other relevant documents with this form.
This information is being collected in compliance with the Data Protection Act. It may be used as necessary by the Education Directorates Authorities. S.E.S. VIFRM A 01/11 MINISTRY FOR EDUCATION AND EMPLOYMENT EDUC/01/02/06 DIRETTORAT GĦAL SERVIZZI EDUKATTIVI DIRECTORATE FOR EDUCATIONAL SERVICES DIPARTIMENT SERVIZZI GĦALL-ISTUDENT STUDENT SERVICES DEPARTMENT SETTUR EDUKAZZJONI SPEĊJALI SPECIAL EDUCATION SECTOR TRIQ FRA GAETANO PACE FORNO, FRA GAETANO PACE FORNO STREET, ĦAMRUN HMR 1100 HAMRUN HMR 1100
TEL: 21228349 / 50 MALTA
STATEMENT OF CONSENT BY PARENTS / LEGAL GUARDIAN
I hereby give consent to the Directorate for Educational Services to process and record personal and
sensitive data being herewith in order to be able to render me the service I am applying for.
I fully understand that:
1. by opting out, my application cannot be processed;
2. authorised personnel who are processing this information may have access to this data in order to
supply me and members of my family with the service being applied for;
3. edited information, that would not identify me or any member of my family, may be included in
statistical reports.
I know that I am entitled to see the information, related to me, should I ask for it in writing.
I am aware that for purpose of the Data Protection Act, the Data Controller is: Directorate for Educational
Services – Director, Student Services Department – Fra Gaetano Pace Forno Street, Hamrun HMR 1100 and
Room 316, Great Siege Road, Floriana VLT 2000.
I have read and understood this statement of consent myself
This statement of consent was read and explained to me
DATA SUBJECT STUDENT'S NAME READER (If applicable)
NAME NAME
MOTHER FATHER PROFESSION /GRADE
LEGAL GUARDIAN
SIGNATURE SIGNATURE
ID No DATE: ID No DATE:
______
This information is being collected in compliance with the Data Protection Act. It may be used as necessary by the Education Authorities. EDUC 01/02/05
MINISTRY FOR EDUCATION AND EMPLOYMENT