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Application Form:

 

to be placed on our waiting list

(For a printable PDF version CLICK HERE)

CHILD:

First name/s: Surname: Hebrew name/s:

Gender: M F Date of Birth: (DD/MM/YYYY - please insert "/ " between dates)

Country of birth: Language/s spoken:

 

MOTHER / FATHER / GUARDIAN: ( Primary account holder - this person os registered or likely to register for Child Care Benefit and/or Child Care Rebate).

Title:

First name/s: Surname: Hebrew name/s:

Relationship to the child (eg, Mother/Father/Guardian):

Gender: M F Country of Birth: Language/s spoken:

Mobile: Home: Email:

Home Address:

Street address:

Suburb: State: Postcode:

Mailing Address: Check if mailing address is same as home address. If not, fill in below:

Street Address:

Suburb: State: Postcode:

Best communication method: In person Email PhoneOther:

MOTHER / FATHER / GUARDIAN: ( Secondary account holder).

Title:

First Name: Surname: Hebrew Name/s:

Relationship to Child (eg, Mother/Father/Guardian):

Gender: M F Country of Birth: Language/s Spoken:

Mobile: Home: Email:

Home Address:

Street Address:

Suburb: State: Postcode:

Best communication Method: In Person Email Phone Other:

Mailing Address: Check if Mailing address is same as home address. If not, fill in below:

Street Address:

Suburb: State: Postcode:

ATTENDANCE DETAILS:

Prospect Start Date (DD/MM/YYYY):

Room/age group:

Days Required (select more than one if required):

The above choice of days is: Specific or; Flexible

Times Required (please indicate the likely drop off and pick up times):

Monday: Drop Off: Pick Up:

Tuesday: Drop Off: Pick Up:

Wednesay: Drop Off: Pick Up:

Thursday: Drop Off: Pick Up:

Friday: Drop Off: Pick Up:

Please note that we cannot guarantee days but we will do our best to accommodate.

CONSENT:

  • I declare that the information in this form is true and correct and undertake to immediately inform the Centre of any change to this information.
  • I understand that the submission of this form will place my child on a waiting list. I will be notified in writing of a placement at the Centre.

By checking this box I, the Primary Account Holder agree to all the above. Date:

By checking this box I, the Secondary Account Holder agree to all the above. Date:

FEE:

Please submit the completed Application Form, together with the administration fee of $100 and you will be advised of your child/children place/places. The Fee is 50% refundable if the Centre is unable to offer your child a place.

Please charge my Credit Card $100:

Visa / Matercard Number:

Expiry (mm/yy):

Name on Card:

Check here to sign.

Date: