EV Early Years Manager - Application Form

Kindergarten Application Form

EV Early Years Manager
Welcome to EV EYM. This is your first step towards enrolling your little one into one of our kindergartens. Please take the time to review and complete the form.
Deferral Form

Yes
input_year
Family Details
Child's Name*

First NameLast Name
Gender*

MaleFemaleUnspecified
Child's Date of Birth*

DayMonthYear
Parent / Guardian 1*

First NameLast Name
Relationship to the child*
Parent / Guardian 1 Address*

Street Address

Street Address Line 2

CityState

Post Code
Mobile Number*
Email*
Please Note: You will be notified of all correspondence via email
Does Parent / Guardian 1 hold a Commonwealth Health Care Card?*

YesNo
Health Care Number*
Health Care Expiry Date*

DayMonthYear
Please attach a copy of your Health Care card*

Cancelof
Does Parent / Guardian 1 hold a Commonwealth Pensioner Concession Card?*

YesNo
Pensioner Number*
Pensioner Card Expiry Date*

DayMonthYear
Please attach a copy of your Pensioner Concession card*

Cancelof
Does Parent / Guardian 1 hold a Veterans Affairs Card?*

YesNo
Department of Veterans Affairs Number*
Department of Veterans Affairs Expiry Date*

DayMonthYear
Please attach a copy of your Department of Veterans Affairs card*

Cancelof
Does Parent / Guardian 1 have a NDIS number or are they undergoing assessment for disability under the NDIS currently?*

YesNo
Does Parent / Guardian 1 have complex medical needs that present barriers to accessing a kindergarten program (supported by a letter from a medical practitioner or specialist)?*

YesNo
Please provide further details*

0/230
Please attach a copy of the assessment or letter*

Cancelof
Does Parent / Guardian 1 require an interpreter?*

YesNo
Would you like to add a second parent / guardian?*

YesNo
Parent / Guardian 2*

First NameLast Name
Relationship to the child*
Parent / Guardian 2 Address*

Same as parent / guardian 1Different to parent / guardian 1
Parent / Guardian 2 Address*

Street Address

Street Address Line 2

CityState

Post Code
Phone Number*
Email*
Does Parent / Guardian 2 hold a Commonwealth Health Care Card?

YesNo
Health Care Number*
Health Care Expiry Date*

DayMonthYear
Please attach a copy of your Health Care card*

Cancelof
Does Parent / Guardian 2 hold a Commonwealth Pensioner Concession Card?

YesNo
Pensioner Number*
Pensioner Number*
Pensioner Card Expiry Date*

DayMonthYear
Please attach a copy of your Pensioner Concession card*

Cancelof
Does Parent / Guardian 2 hold a Veterans Affairs Card?

YesNo
Department of Veterans Affairs Number*
Department of Veterans Affairs Expiry Date*

DayMonthYear
Please attach a copy of your Department of Veterans Affairs card*

Cancelof
Does Parent / Guardian 2 have a NDIS number or are they undergoing assessment for disability under the NDIS currently?*

YesNo
Does Parent / Guardian 2 have complex medical needs that present barriers to accessing a kindergarten program (supported by a letter from a medical practitioner or specialist)?*

YesNo
Please provide further details*

0/230
Please attach a copy of the assessment or letter*

Cancelof
Language/s spoken at home:
Kindergarten Preferences
What year would you like your child to commence care? *
Please indicate if your application is for 3 Year Old or 4 Year Old Kindergarten*
Preference One*
Preference 1*
Preference Two*
Preference Three
Please note: Based on the Date of birth you have provided, your child is too young to commence 3 Year Old Kindergarten in the year you have selected. Please contact us if you wish to discuss further.
Please attach confirmation of your address (eg. rates notice or a bill) *

Cancelof
Would you be interested in learning more about the After Kinder Care at The Patch Kindergarten?*

YesNo
Would you be interested in learning more about the Nature Play Sessions at Kallista Kindergarten?*

YesNo
Additional Information About Your Child
By completing the following information, you will help our team support your family. This information will also be used to access priority of access for a kindergarten placement
Do you or your child have, or are you applying for, any of the following visas?

Refugee visa (subclass 200)In-country Special Humanitarian visa (subclass 201)Global Special Humanitarian visa (subclass 202)Temporary Humanitarian Concern visa (subclass 786)Protection visa (subclass 866)Emergency Rescue visa (subclass 203)Woman at risk visa (subclass 204)Bridging visa A-E for humanitarian or refugee visaHumanitarian Stay visa (subclass 449)Temporary Protection visa (subclass 785)Safe Haven Enterprise visa (subclass 790)Current or expired ImmiCard
Please attach a copy of your concession / visa*

Max 10MB total file size
Cancelof
Please note: The eligibility of concessions may vary from time-to-time. Up-to-date information can be found at: https://www.vic.gov.au/kindergarten
Do you or your child hold a Commonwealth or Disability Health Care Card?*

YesNo
Health Care Number*
Health Care expiry date*

DayMonthYear
Please attach a copy of the Health Care card*

Cancelof
Do you or your child hold a Pensioner Concession Card*

YesNo
Pensioner Number*
Pension Card Expiry Date*

DayMonthYear
Please attach a copy of your Pensioner Concession card*

Cancelof
Do you hold a Veterans Affairs Card?*

YesNo
Please attach a copy of your Department of Veterans Affairs card*

Cancelof
Is this child Aboriginal or Torres Strait Islander?*

NoTorres Strait IslanderAboriginalBoth Aboriginal and Torres Strait Islander
Is this child a multiple birth (triplet or quadruplet or more)?*

YesNo
Does the child have complex medical needs that present a barrier to accessing a kindergarten program?*

YesNo
If yes, please select which of the following applies*

Child eligible or undergoing assessment for a disability under the NDISChild eligible for Early Childhood Intervention Service Continuity of SupportChild diagnosed with a disability or developmental delay or undergoing diagnosisChild with developmental concerns that presents barriers to accessing a kindergarten programChild has complex medical needs that presents barriers to accessing a kindergarten programChild holds Disability Health Care CardChild previously accessed Kindergarten or Commonwealth Inclusion Support or similar programReferred by NDIS or Early Childhood Intervention or Preschool Field Officer or MCH nurse or similar
Please attach a supporting letter from a medical practitioner or specialist*

Cancelof
Is this child or family at risk?*

YesNo
If yes, please select from the following:*

Experiencing family violence or has had contact with The Orange DoorKnown to or had contact with Child Protection or in Out-of-Home-CareChild or family previously accessed Flexible Support PackagesReferred by Child Protection, Child and Family services, MCH nurse, Out of Home Care provider
Are there any court orders relating to the powers, duties, responsibilities or authorities of any person in relation to the child or access to the child?*

YesNo
Second Year of Funded Kindergarten
Children enrolled in a funded kindergarten program are eligible to access a repeat year of funded 3 or 4 year old kindergarten, only if the early childhood teacher has assessed eligibility for your child to be considered for a second year.
Is this enrolment related to a second year of funded {forminput_programtype}?*

YesNo
ty_repeat

3YO4YO
ny_repeat

3YO4YO
Has your child or an older sibling attended the service of your first preference in the last 3 years?*

YesNo
How did you hear about us?*

FacebookWord Of MouthInternet SearchPreviously AttendedLetterbox DropOther
Authorisation and Declaration
By submitting this registration form, I understand and agree to the following:
- All information provided by me is true and correct
- All information provided by me may be audited at any time. This registration or subsequent kindergarten allocation could be reallocated or withdrawn if the information is incorrect
- Failure to provide complete and correct information may result in the registration being excluded from the allocation process
- This is a registration form and does not guarantee a three or four-year-old kindergarten placement
- Three and four-year-old kindergarten places are allocated separately. Every effort will be made to place my child at the same service for four-year-old kindergarten. However, there is no guarantee of this.
- I can be contacted by EV EYM from time to time with information regarding relevant events, issues and services
- To participate in the Central Registration Scheme my personal information will be shared securely with the preferred kindergarten service provider nominated by me on this or subsequent forms
Data Collection and Privacy
Already Paid?

Yes
Payment Name
Amount
Payment Type
Surpress Notifications
Payment Reference Number
Todays Date

DayMonthYear
Date
Cutoff date calculator
Cutoff Date

DayMonthYear
Date
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Age as at cutoff
ineligible to apply
form_name
DNU Has this child received a funded 4YO kindergarten place before?

YesNo
If yes, please specify:
Is your child registered with a specific Support service / agency?

YesNo
Name of support service / agency:
Should be Empty:

Kindergarten Application Form

Family Details

Kindergarten Preferences

Additional Information About Your Child

Authorisation and Declaration