EmailMe Form - PP Expression of Interest for Enrolment Form

Child's Full Name *

First Last

Child's Date of Birth *

Child's Gender *

Main Home Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Parent/Carer 1 Name *

First Last

Phone *

Best Contact Number

Email *

Occupation

Main Home Address (If different from child) *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Parent/Carer 2 Name

First Last

Phone

Best Contact Number

Email

Occupation

Main Home Address (if different from child)

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Languages spoken / Cultural Background - Child

Languages spoken / Cultural Background - Parents

Is your child of Aboriginal and / or Torres Straight Islander Descent?

Aboriginal

Torres Straight Islander

Do you have a low income or pension card?

Yes

No

Name of Emergency Contact (If we are unable to contact you)

First Last

Phone

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Relationship to Child

Does, or has your child suffered from any serious illnesses or accidents?

Government funding may be available if your child has experienced any language, speech difficulty, physical or intellectual disabilities, behavioural problems, or other health issues.
Please detail:

Has your child attended Early Intervention?

Yes

No

Enrolment Preference: Please Choose two days

What is your preferred start date? *

Do you have any additional information you would like to add?
(is your child attending another service, carers working full time etc)

Signature

Clear

Date Time *

DD / MM / YYYY