Centre Location*Childcare - CarindaleChildcare - Pine RiversKindergarten
Surname*
Phone*
Child's First Name*
D.O.B.*
Gender*MaleFemale
Street Address*
Address Line 2
City*
State/Province*
Zip/Postal Code*
Name*
Home Phone*
Work Phone*
Occupation*
Mobile*
Email*
Program*ChildcareKindergarten
Expected Start Date
Which DAYS would you prefer to attend?*MondayTuesdayWednesdayThursdayFriday
Name
Age
1st Priority: A child at risk of serious abuse or neglect. 2nd 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 Family Assistance Act. 3rd Priority: Any other child.
Please tick the categories that apply to you:*
Child at risk of serious abuse or neglectEmployed FullEmployed Part timeStudying/TrainingChild has a disabling conditionParent with special needsMoving to Aust / QldSingle parent familyTwo Parent familyNon-English speaking familyChild has Aboriginal/Tor St backg’dIntegrate child’s social skillsOther
Date*
Parent's Signature:*
Please note that the information collected is for Centre use only. It will be used to assess your priority category & to obtain contact details, which are to be used during the enrolment process. (Privacy Act – December 2002)
We’d love to hear from you and see what we can do for you and your child.
childcare@citipointechurch.com
