CHILD *

First Name

Last Name

DOB *

MM

DD

YYYY

Gender *

Male

Female

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

PARENT 1 *

First Name

Last Name

Mobile *

(###)

###

####

Home Phone

(###)

###

####

PARENT 2

First Name

Last Name

Mobile

(###)

###

####

Home Phone

(###)

###

####

Please tick your preference of days for enrolment

Care and education is available from 8.30am-4.00pm and each room routine runs from 9.00am-3.00pm.

2 days

3 days

Consecutive days

PRIORITY OF ACCESS

Please tick any of these that apply to your family as some categories have a priority of access for preschool places:

Health care card (please attach to this form)

Disability (child or parent)

Aboriginal or Torres Strait Islander

Diverse cultural background

CHILD DETAILS

Does your child have a speech or developmental delay?

Yes

No

Does your child attend an intervention service or therapist?

Yes

No

Does your child have any medical conditions?

Yes

No

I HAVE ATTACHED A COPY OF MY CHILD’S IMMUNISATION RECORD STATEMENT TO THIS FORM *

Yes

No