Surf Coast Shire - Draft - Integrated Registration Form

Kindergarten Central Application Form
Surf Coast Shire Council manages and supports the early years programs for Kurrambee Myaring Kindergarten (Torquay), Torquay Kindergarten, Helen M Kininmonth Kindergarten (Winchelsea), Jan Juc Pre‑School, Anglesea Kindergarten and Lorne Kindergarten.

All our Three- and Four-Year-Old Kindergarten programs are free, thanks to the Victorian Government’s Best Start Best Life Reforms.
Contact us

If you have any questions regarding the application please contact us via email centralapplication@surfcoast.vic.gov.au
Kindergarten Preferences
Date

DayMonthYear
Date
When to start Three and Four-Year-Old Kindergarten
Use the Starting Age Calculator to enter your child's birth date to find out what year they can start Three and Four-Year-Old Kindergarten.

Starting age calculator
What year would you like your child to commence in kindergarten? *
What year would you like your child to commence in kindergarten? *
Mapped Care Period *
What Program Type is this application relevant to?*
Child's Details
Child's Name*

First NameMiddle NameLast Name
MaleFemale
MaleFemaleSelf – described (specify)
Child's Date of Birth*

DayMonthYear
WARNING: YOUR APPLICATION IS UNABLE TO BE ACCEPTED ONLINE.

Based on the Date of Birth entered for this child, they will not meet the age criteria for the year selected above. Please either change the year selected or contact us via email to discuss at centralapplication@surfcoast.vic.gov.au.
Both parentsParent / Guardian 1Parent / Guardian 2Formal Kinship CareFoster CarePermanent CareResidential CareInformal Kinship Care
Language/s spoken at home:*
Contact Details
Parent / Guardian 1*

First NameLast Name
Relationship to the child*
Address*

Street Address

Street Address Line 2

CityState

Post Code
Phone Number*
Email*
Please Note: You will be notified of all correspondence via email
YesNo
Health Care Number*
Health Care Expiry Date*

DayMonthYear
Please attach a copy of your Health Care card*

Cancelof
YesNo
Pensioner Card Number*
Pensioner Card Expiry Date*

DayMonthYear
Please attach a copy of your Pensioner Concession card*

Cancelof
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
YesNo
YesNo
Please provide further details*

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

Cancelof
YesNo
Parent / Guardian 2*

First NameLast Name
Relationship to the child*
Same as parent / guardian 1Different to parent / guardian 1
Address*

Street Address

Street Address Line 2

CityState

Post Code
Phone Number*
Email*
YesNo
Health Care Number*
Health Care Expiry Date*

DayMonthYear
Please attach a copy of your Health Care card*

Cancelof
YesNo
Pensioner Card Number*
Pensioner Card Expiry Date*

DayMonthYear
Please attach a copy of your Pensioner Concession card*

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

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

Cancelof
YesNo
YesNo
Please provide further details*

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

Cancelof
YesNo
Immunisation Details
The Government’s No Jab No Play laws require all children to be age-appropriately immunised before enrolment can be confirmed. Further information on immunisation requirements for enrolment in early childhood services is available on the State Government's Better Health Channel at www.betterhealth.vic.gov.au/campaigns/no-jab-no-play
YesNo
Please attach your child's immunisation history statement*

Cancelof
An Immunisation History Statement from the Australian Immunisation Register is the only documentation accepted by early childhood education and care services for the purposes of confirming a child’s enrolment in their service
Priority of Access - Additional Information
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 and access to additional hours for priority cohorts (as defined by the Department of Education).
NoTorres Strait IslanderAboriginalBoth Aboriginal and Torres Strait Islander
YesNo
Health Care Card Expiry Date*

DayMonthYear
Health Care Number*
Please attach a copy of the Health Care card*

Cancelof
YesNo
Refugee visa (subclass 200)In-country Special Humanitarian visa (subclass 201)Global Special Humanitarian visa (subclass 202)Humanitarian Stay visa (subclass 449)Temporary Protection visa (subclass 785)Safe Haven Enterprise visa (subclass 790)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 visa)Current or expired ImmiCard
Supporting documentation will need to be sighted at the time of enrolment
Children or family at risk is defined as:
- Experiencing family violence or has had contact with The Orange Door
- Known to or had contact with Child Protection or in Out-of-Home-Care
- Child or family previously accessed Flexible Support Packages
- Referred by Child Protection, Child and Family services, MCH nurse, Out of Home Care provider
YesNo
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
Please attach a copy of relevant documentation

Max 10MB total file size
Cancelof
P1 Eligible?
P2 Eligible?
Input PPPC
Pre Prep Priority Cohort
Pre-prep priority gives eligible children between 16-25 hours of free kindergarten per week. To be eligible, your child must be four by 30 April in the year they start kindergarten, and:
- is from a refugee or asylum seeker background, or
- identify as Aboriginal or Torres Strait Islander, or
- your family has had contact with child protection.
The Kindergarten Engagement Officer will contact you to discuss available options.
Yes
Early Start Kindergarten gives eligible children 15 hours of free kindergarten a week. To be eligible, your child must be three by 30 April in the year they start kindergarten, and:
- is from a refugee or asylum seeker background, or
- identify as Aboriginal or Torres Strait Islander, or
- your family has had contact with child protection.
The Kindergarten Engagement Officer will contact you to discuss available options.
YesNo
Name of support service / agency*
max 255 characters
YesNo
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 specify:*

0/255
You are encouraged to discuss your child's needs with the educator when your child's place is confirmed.
YesNo
1. If there are court orders in place relating to your child, you must bring the original court order/s for staff to see and attach a copy to this enrolment form.

2. If these orders change the powers of a parent /guardian to:
• authorise the taking of the child outside the service by a staff member of the service;
• consent to the medical treatment of the child;
• request or permit the administration of medication to the child;
• collect the child from the service or family day care; and/or
• give these powers to someone else.
Please describe these changes and provide the contact details of any person given these powers in the space below:*
Please attach a copy of order(s) and bring original copy for educators to sight*

Cancelof
YesNo
Sibling 1 Details*
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.
YesNo
What Kindergarten is your child currently attending?
Authorisation & Declaration
By submitting this application the parent/guardian agrees and understands:
- I declare that all of the information provided on this application form is true and correct and I will update Surf Coast Shire of any changes.
- 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
- This is an application form, not a guarantee of kindergarten placement.
- Kindergarten groups are subject to change (days, times, size, and type) at any time
Collection Notice

Surf Coast Shire Council is committed to protecting your privacy and is bound by the Information Privacy Principles in the Privacy and Data Protection Act 2014 (Vic) ('PDP Act') and Health Privacy Principles in the Health Records Act 2001. The personal information requested on the form is being collected by Council for the purpose of enrolling your child into the Kindergarten program. If the personal information is not collected, we will be unable to enrol your child into the program, and/or we will be unable to contact you for further questions or solutions. We will not disclose your personal information without your consent, except where required or authorised to do so by law. Our privacy policy is available on our website. If you wish to alter any of the personal information you have supplied to Council, please contact us by sending an email to info@surfcoast.vic.gov.au.
Send Notification to family?
Yes
Yes
Yes
crm_orgid
current_service_allocated
Same Service Priority
Suppress Notifications
Program Type Input
Care Period Input
Offer Response
form_name
Cutoff date calculator
Cutoff Date

DayMonthYear
Date
Age as at cutoff
ineligible to apply
Token
YesNo
Pensioner Number
Pensioner Expiry Date

DayMonthYear
YesNo
DNU_Please specify:*

0/255
Should be Empty:

Kindergarten Central Application Form

Kindergarten Preferences

Child's Details

Contact Details

Immunisation Details

Priority of Access - Additional Information

Authorisation & Declaration