Child 1 *

First Name

Last Name

Child 1 DOB *

MM

DD

YYYY

Child 2

First Name

Last Name

Child 2 DOB

MM

DD

YYYY

Child 3

First Name

Last Name

Child 3 DOB

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Mobile Phone

(###)

###

####

Parent/ Carer 1 *

First Name

Last Name

Parent/Carer 2

First Name

Last Name

Other Parent/Carer

First Name

Last Name

Do you have Transport?

Yes

No

Do you hold a green Health Care Card or Purple Pension Card?

Yes, Pension Card

Yes, HCC

No

Do you, a member of your family or children speak a language other than English at home? *

Yes

No

Is your child up to date with their vaccinations? *

https://www.health.nsw.gov.au/immunisation/publications/nsw-immunisation-schedule.pdf

Yes

No

What days are you hoping to enrol your child/ren? *

n.b. 3-5 year olds eligible for free Preschool is for 2 days only. Additional days are currently $52 each

Monday

Tuesday

Wednesday

Thursday

Friday

When would you like your child/ren to start Preschool? *

MM

DD

YYYY

Do you require extended hours care? *

Enrolled hours are from 8.30am - 4pm for all children. Extended hours are from 8-8.30am and 4-4.30pm for $5 per half hour.

Yes

No

Unsure