2022 School Referral Form
Section A: Important information
This form is to be completed by the student’s most recent school in order to determine a
students eligibility for enrolment with Virtual School Victoria (VSV). Please see page 10 for
further information on eligibility requirements.
VSV recognises that a shared enrolment is often a viable option to provide a strong framework for sustaining
wellbeing supports and learning outcomes for students. For further information, please see page 55.
Full-time enrolment at VSV requires the student to be withdrawn from the environment of your school and its
learning and support systems, to undertake study through online learning platforms from their family home
under the supervision of a parent/carer.
Enrolment is for the current academic year only.
VSV does not receive funding through the Victorian or Commonwealth student disability support funding
programs (PSD, NCCD).
Students enrolled at Virtual School Victoria require supervision by a parent or carer. Supervisors are required to
perform a range of duties including:
facilitating communication between the student and teachers
ensuring age appropriate adult supervision of the student
engaging with material provided by VSV both in a written and verbal format
ensuring that the student has access to a telephone, computer, reliable internet connection, and suitable
work area
supporting the student to engage and participate in the learning program and the wider school community
ensuring the student submits work in accordance with the prescribed or negotiated submission timetable.
2022 School Referral Form
School Details
School Name:
Student Details
Please indicate the student’s
previous school/s if less than one year:
Reason for referral to VSV:
Has this student been assessed for funding through the DET Program for Students with Disabilities?
Has this student been approved for funding through the DET Program for Students with Disabilities?
PSD category:
Level of funding approved:
Has this student been approved for funding through the Commonwealth NCCD?
NCCD category: Level of funding approved:
Year Level
in 2022:
Length of enrolment
at your school:
No Yes
No Yes
No Yes
Autism Spectrum Disorder Severe language disorder
Visual impairment Hearing impairment Severe behaviour disorder
Intellectual disability
Date of Birth:
Level 1 Level 2 Level 3 Level 4 Level 6Level 5
Section B: Information to determine a students eligibility and support their enrolment
Is the student of Aboriginal or Torres Strait Islander origin?
If Yes, please provide a copy of the student’s IEP/ILP.
What is the student's living arrangement?
(Tick one)
If the student is in OOHC,
please provide a copy of their IEP/ILP.
Is the student currently involved with Youth Justice
(in custody, remand or sentence, or in community)?
If Yes, please provide a copy of the student’s IEP/ILP.
No Yes (please specify)
No Yes, Aboriginal
Yes, Torres Strait Islander
Yes, Aboriginal & Torres Strait Islander
Out of Home Care* – statutory/court-ordered
At home with TWO Parents/Carers At home with One Parent/Carer
Out of Home Care – informal
Homeless Youth
Out of Home Care – permanent care
2022 School Referral Form
Evidence of the implementation of a Staged Response
and the students inability to attend a mainstream school
Stage 1 – Early identication and intervention
When did you last see
this student?
How regularly has the student
been attending classes?
What are the main factors
aecting the student's
attendance and engagement
with learning?
Stage 2 – Intervention strategies
How has the students learning
program been modied?
Has a Student Support Group
(SSG) been established?
Provide details and attach
most recent meeting records
and plans.
Has a consultation/referral
occurred with the DET
Health, Wellbeing & Inclusion
workforce or equivalent
Catholic/Independent system?
Have agency or community
service referrals been made?
Provide details (including
key names, contact details,
outcome of referrals and
time frames).
School Transition information
What steps are planned to
support the student to return
to your school or another
appropriate pathway?
What time frame do you
believe will be required to
enable this?
Please attach the following
documents to this referral
(please tick).
By mid-2022
The student’s most recent school report
Career Action Plan (if available)
NAPLAN report (if available)
SSG minutes
Individual Learning Plan (if relevant)
PSD Assessment/approval reports
By the end of 2022 or beyond
Section C: Endorsement of the enrolment
Schools intending to refer students from mandated cohorts (Aboriginal and Torres Strait Islander, Out of Home Care, PSD/
NCCD funded students and students, who are working two years or more below the expected level for their age in both
literacy and numeracy), must liaise with VSV at the time of submitting an enrolment application.
I recommend withdrawal from mainstream schooling and having a full enrolment with VSV.
I recommend a shared enrolment with VSV and an appropriate mainstream school.
If yes, what time fraction at VSV?
I have obtained the consent of the parent/carer or independent student to provide this information
to the Department of Education and Training and VSV.
Please provide a copy of the students current VASS statement to verify completion of past
VCE subject/s. VASS Statement included.
I believe the parent/carer is capable of meeting the supervisor requirements.
I accept that after two terms or six months the referred student’s progress will be evaluated for the continued suitability in
the VSV program. If after this time the student has been continually unable to engage in their individual learning program,
the student will be referred back to their original mainstream school.
Principal's Signature: Date:
2022 School Referral Form
No Yes
No Yes
No Yes
No Yes
No Yes
Once completed, this form can be returned to the parent/carer or sent directly to VSV via post, fax, or email:
Virtual School Victoria
315 Clarendon Street,
Thornbury, VIC 3071
(03) 9416 8487
All information obtained in this form is dealt with in accordance with VSV’s Privacy Policy and the
Department of Education and Training policies and procedures regarding privacy and record keeping.
Queries can be addressed to the VSV Enrolment Oce on (03) 8480 0000.
School contact
To liaise with VSV regarding student progress and possible reintegration to mainstream school
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