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Parent/Carer 1 Details





Gender:
Relationship to Child:





Child’s Details

First Name:
Last Name:
Gender:
Date Of Birth: (DD/MM/YYYY)

Parent/Carer 2 Details

First Name:
Last Name:
Mobile:
Email:
Gender:
Relationship to Child:
Your answers to the following questions are confidential and assist us to determine priority of enrolment and/or your child’s eligibility for additional support at Preschool. Please check the following boxes that apply:
I have a Low Income Family Health Care Card:
Child speaks little or no English:
My child has difficulty learning new things, talking or understanding what others are saying.:
My child has been diagnosed with specific difficulties or disabilities:
Diagnosis:
My child is from an Aboriginal or Torres Strait Islander background:
Health or Medical Condition:

Does your child currently attend an early learning service? Eg; Child Care Centre or Preschool
Please indicate your preferred day to attend the program:
Any further comments regarding your child?