Waiting List Application

Date Received By Centre:
Child’s Surname: ____________________ First Name: ___________
Date of Birth/Expected Date of Birth: ___________ Male/Female
Address: _____________________  Post Code: ________
Parent 1: ________________      Parent 2: ___________________
Address: ____________________ Address: ___________________
           ____________________            ___________________
Home Phone: _________________ Home Phone: __________________
Employer: ___________________ Employer: __________________
Department: _________________ Department: ________________
Position: ____________________ Position: ____________________
Work Phone: ________________ Work Phone: _________________
Email: _____________________   Email: _____________________
Contact Other Than Parent:
Name: ________________ Hm Ph: __________ Wk Ph: ________
Child Care Details:
Date Care Required From: ____________________
Days of Care Required: M T W T F (please circle)
Are you interested in accepting other days if they become available? Y/N
Do you wish to book in for permanent days? Y/N
Do you wish to utilise a rotating roster place where you nominate an amount of days to use in according to your monthly roster? Y/N

Does your child have any additional needs that we need to be aware of, please explain.______________________________________________________

Parent Signature: ____________________ Date: _____________