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Child
Name
*
First
Last
Gender
*
Male
Female
Date of Birth
*
DD slash MM slash YYYY
Age
*
3yo / 4yo - 8.30-1.30 (5 HOURS P/W)
4yo / 5yo - 2 FULL DAYS 8.30-4.00 (15 HOURS P/W)
More Information
Aboriginal or Torres Strait Islander
From a non-English speaking background
Attends other childrens services
Will be attending another preschool
Has your child been referred to any other services?
Speech Therapy
Occupational Therapy
Early Intervention
Other
Other services
*
Does your child have any identified additional needs?
Yes
Eg: Speech, Mobility, Sensory, Processing, Behavior, Toileting, Aggression
Please provide further information
*
Note:
It is very important we are made aware of any additional needs as early as possible, so we can apply for funding as required to support your child's participation within the preschool and the program.
Year to Start Preschool
*
Year to Start Primary School
*
Parent/Guardian
Name
*
First
Last
Relationship
*
Mother
Father
Guardian
Email
*
Mobile
*
Other Phone
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Add secondary contact?
Yes
Other Parent/Guardian
Name
*
First
Last
Relationship
*
Mother
Father
Guardian
Email
*
Mobile
*
Other Phone
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Authorisation
Signature
*
I am authorised to submit this information on behalf of the child
By checking this box you are providing your electronic signature.
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