Samanthas Application Form

Samantha's Child Care Centre and Kindergarten

Waitlist Form
Carrum Downs Early Learning Centre

Waitlist Form
Deferral Form

Yes
Program Type
Child Details
Child's Name*

First nameLast name
Gender*

MaleFemaleOther
Child's date of birth*

DayMonthYear
Parent's Details
Parent / Guardian 1*

First nameLast name
Gender*
Phone Number*
Email*
Please note: you will be notified of all correspondence via email. This email will be used for all future correspondence unless otherwise advised.
Address*

Street Address

Street Address Line 2

SuburbState

Postcode
Care Requirements
Waitlisted Service
Preference One*
When would you like to access care for this child?*

DayMonthYear
Date
What year does this registration apply for?*
Age at Start Date
How many days of care do you require?*
What days of week do you require care (please select all that are possible)?*

MondayTuesdayWednesdayThursdayFriday
What service is this registration for?
What program type is this application relevant to? *
Access Priority Questions

Allocation of available places is made in accordance with the Australian Government's Priority of Access Guidelines and other information gathered from you as part of this waitlist process. Please answer the following questions to ensure we can assess your waitlist accordingly.
Is this child at risk of serious abuse or neglect*

YesNo
Do both parents (or in the case of single parent family, does the parent) satisfy, the work/training/study test under Section 14 of the 'A New Tax System (Family Assistance) Act 1999*

YesNo
Does this child have a medical condition or any additional needs*

YesNo
Please provide details of the medical conditions and needs*

0/250
Does this family have a prior connection to this service*

YesNo
Please provide details of prior connection*
Would you like to send a confirmation email for this change?
alreadyPaid
waitlistValidation
Todays date

DayMonthYear
Date
Validation Year
Should be Empty:

Samantha's Child Care Centre and Kindergarten

Carrum Downs Early Learning Centre