Application For Enrolment Form

Child’s Surname:

Child's First Name:

Child's Date Of Birth:


Parent 1

Parent 2

Parent's Names

Contact Phone

Contact Email

Place Of Employment/Education Institute

Work Phone

Priority of placement is a Commonwealth Government Directive. DEEWR state the Priority of Access must be given to the following categories, please tick which applies to you:

 First Priority: a child at risk of serious abuse or neglect Second Priority: a child of a single parent who satisfies, or of parents who both satisfy, the work/training/study test under Section 14 of the 'A New Tax System (Family Assistance) Act 1999' Third Priority: any other child.

Do you or your child have any health problems or disability?

Any special family circumstances?

Has your child attended Long Day Care before?

 Yes No

If Yes, which centre did they attend?

Does your child currently attend another centre?

 Yes No

Do you have a case worker with Communty Services?

 Yes No

If Yes, what is the name of the worker?

What are the number of days' attendance required?  Monday Tuesday Wednesday Thursday Friday

What times do you require?

Please indicate when you would like attendance from (date)

Thank you for your application, we will contact you for an interview when a suitable position becomes available.

Please copy this code into the box below: