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Kath
Enquiry Form
"
*
" indicates required fields
Parent/guardian name
*
Email
*
Phone
*
Child's first name
*
Child's date of birth
*
MM slash DD slash YYYY
Is your child toilet trained?
*
Yes
No
Does your child have any food allergies?
*
Yes
No
Does your child have any additional needs?
*
Yes
No
Does your child have any medical conditions?
*
Yes
No
Preferred start date
*
MM slash DD slash YYYY
Please select what days you are interested in
*
Monday
Tuesday
Wednesday
Thursday
Friday
Would you like to arrange a tour of the centre?
*
Yes
No
What days and times work best for a center tour?
*
Any additional information you would like to provide?
*
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Waiting List Form
"
*
" indicates required fields
Child Information
Surname
*
Given Name/s
*
Date of Birth
*
Month
Day
Year
E.D.D
*
Sex
*
M
F
Languages spoken at home:
*
Known disabilities, diagnosis, allergies or illnesses:
*
Child Care Requirements
Month Required:
Year Required:
No. Of Days Required:
Tick preferred Day / s:
*
Monday
Tuesday
Wednesday
Thursday
Friday
Number Priority (1 being highest priority):
*
Monday
Tuesday
Wednesday
Thursday
Friday
Are you flexible with your days:
*
Yes
No
Are you flexible with your start date:
*
Yes
No
Parent/Guardian Information
Parent/Guardian 1
Parent/Guardian 2
Title / First name:
*
Title / First name:
*
Family name:
*
Family name:
*
Address:
*
Home Address
Postcode
Address:
*
Home Address
Postcode
Home Phone:
Home Phone:
Work Phone:
Work Phone:
Mobile:
Mobile:
Email:
Email:
Ethnicity:
Ethnicity:
Languages spoken:
Languages spoken:
Are you any of the following:
Are you any of the following:
Working:
Yes
No
Working:
Yes
No
Have a disability:
Yes
No
Have a disability:
Yes
No
Maternity/Paternity leave:
Yes
No
Maternity/Paternity leave:
Yes
No
Of Aboriginal descent:
Yes
No
Of Aboriginal descent:
Yes
No
Studying:
Yes
No
Studying:
Yes
No
Single parent:
Yes
No
Single parent:
Yes
No
Not working:
Yes
No
Not working:
Yes
No
Seeking work:
Yes
No
Seeking work:
Yes
No
Priority Of Access
Please tick the applicable priority of access:
*
Both parents or single parent working or studying
Children of parents with a disability / disadvantage
Children at risk of harm
One or both parents at home
Additional Information
It is your responsibility to notify us of any changes to the information supplied. Some changes to circumstances may affect your chances of being offered a placement within our centre. By filling out this form, your child’s name will go on the Waiting List. You will be contacted when a suitable position becomes available. This form does not guarantee that you will be offered a position.
Declaration
The information I have supplied within this form is to the best of my knowledge, true and correct and I will inform the centre if any changes occur.
Please check to add signature
Check to add signature
Date:
*
Month
Day
Year
Signature
*
Please use a mouse or stylus to sign name
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