Australian Dental Association Student Authority form

Instructions for applicants

The Graduate Diploma of Dental Implantology is offered in partnership with ADA NSW Centre for Professional Development (ADA) and Charles Sturt University (Charles Sturt). Since it combines ADA and Charles Sturt subjects there will be a need for Charles Sturt to exchange your personal information with ADA to enable them to administer your enrolment. This personal information may include (but is not limited to):

your student enrolment details;
outstanding debts on your Charles Sturt account;
final grades;
your application for admission to the Program;
your contact details;
information relating to your progress and grades in the Program;
details of any issues of academic or other misconduct in which you are or have been involved; and
any other information reasonably required for the purposes of administering the Program.

This form is to authorise Charles Sturt to exchange information with ADA.

Charles Sturt is unable to deal with ADA on your behalf until we receive your authorisation. This may affect your enrolment and release of your results.

Required fields are marked with an asterisk (*).

Your details

Family name *

Given name(s) *

Date of birth *

Contact telephone no. *

Email address *

Student number

By submitting this authority, under the provisions of the Privacy and Personal Information Protection Act 1998 (NSW), I authorise Charles Sturt University to provide the Australian Dental Association with any personal information deemed necessary to enable them to administer my enrolment and process third party billing arrangements on my behalf.