Waiting List Application Form
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1Waiting List Application
Form
Child’s Details
First name:
Surname:
Date of birth:
Gender (please circle):
Male
Female
Languages spoken:
Cultural background:
Has your child been diagnosed as having an additional need? If yes, please specify: _______________________
Area of Need (please tick below if known):
ADHD
Language Development
Social/Emotional Development
Physical Development
Intellectual Development
All of the Above Areas
Does your child have any medical conditions? If yes, please specify:
Family Details
Parent 1
Parent 2
Name:
Name:
Relationship to child:
Relationship to child:
Address:
Address:
Postcode:
Postcode:
Email Address:
Email Address:
Contact Numbers:
Contact Numbers:
Home:
Home:
Work:
Work:
Mobile:
Mobile:
Occupation:
Occupation:
Date of Birth:
Date of Birth:
Family Requirements
Please circle the required days of care:
Monday
Tuesday
Wednesday
Thursday
Friday
Please indicate the month and year you wish for care to commence: ________ /________
Are you flexible with the days requested?
Yes
No
Priority of Access Guidelines
To comply with the Australian Government and our Priority of Access Guidelines,
families are required to complete the following information.
Please circle the information that applies to you. Are you a:
A Single Parent Family
Mother/Father
Working full time
Working part time
Seeking employment
Studying
Not working outside
home
A Two Parent Family
Mother
Working full time
Working part time
Seeking employment
Studying
Not working outside
home
Father
Working full time
Working part time
Seeking employment
Studying
Not working outside
home
We would like to know how you found out about our service. Please tick the appropriate box(es)
word of mouth
yellow pages/phone book
website
printed material
other_________________________
Applicants Signature: ___________________________________
Date: ___________________________
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