Join our waitlist
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*
" indicates required fields
PARENT/GUARDIAN DETAILS
Your Email
Name
*
Firstname
Surname
Your Date of Birth
*
DD slash MM slash YYYY
Address
*
Street Address
City
State
Postcode
Do you have a Healthcare card/Pension Card
*
Yes
No
Are you of Aboriginal and/or Torres Strait Islander origin?
*
Yes
No
CHILD DETAILS
Child's First Name
*
Child's Surname
*
Date of Birth
*
DD slash MM slash YYYY
Indigenous Status
Not stated
First Nations and Torres Strait Islander
First Nations not Torres Strait Islander
Not First Nations nor Torres Strait Islander
Torres Strait Islander not First Nations
Does this child belong to an existing/previous family?
*
Yes
No
Gender
*
Male
Female
Additional Supports Needed?
*
Yes
No
Additional Supports Information
DAYS REQUESTED
Days requested
1
2
3
4
5
Preferred Start Date
DD slash MM slash YYYY
School Days
*
Monday
Tuesday
Wednesday
Thursday
Friday
Any Days
CONTACT DETAILS
Email
*
Phone
*
Comments
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