REQUEST FOR CHILD CARE

Date:

How did you learn about our service? 

Yellowpages Newspaper Radio Brochure or Flyer Word of Mouth

  Hold CTRL key & click to select multiple choices   

Name       

Address    

Address 2 

Post Code      Suburb 

        Telephone numbers

Home     

  Mobile     

Work  

        Email Address   

Please complete all questions below & submit form:

   PRIORITY OF ACCESS

First Priority - Child at risk of Serious  Abuse or Neglect

Second Priority - A child of a single parent who satisfies, or of parents who satisfy the work/training/study test under Section 14 of FAO Act

Third Priority - Any other child

DATE & TIME YOUR CHILD CARE NEEDS TO COMMENCE:

Is transport required?     Yes    No

Does your child attend another child care service?     Yes    No

Name of Service       

Pre/School Attended 

Child's Name      Date of Birth 

Child's Name      Date of Birth 

Child's Name      Date of Birth 

Child's Name      Date of Birth 

Child's Name      Date of Birth 

Please enter below the days and hours of care that you require.

The fee charged is calculated on the booked hours only.

Comments: