Waitlist Application

Centre Location*

Carindale
Pine Rivers

Surname:*

Phone*

Child’s First Name:*

D.O.B*

Gender*

Male
Female

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Parent 1

Name*

Home Phone*

Work Phone*

Occupation*

Mobile*

Email*

Parent 2

Name

Home Phone

Work Phone

Occupation

Mobile

Email

Program*

Childcare
Kindergarten

Childcare options*

Monday
Tuesday
Wednesday
Thursday
Friday

Kindergarten Options

Monday, Tuesday, Wednesday, Thursday & Friday
Monday, Tuesday & Wednesday
Thursday & Friday

Expected start date

Siblings on waitlist:

Name	Age

PRIORITY OF ACCESS TO CARE

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:*

Other

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)

Non-Refundable Fee

Price: $ 11.00

Date Received

Credit Card

American Express

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name