Centre*
Centre 2 (second preference)*
Date of Application*
Child's First Name*
Child's Family Name*
Birth Date*
Gender* FemaleMale
Name 1
First Name*
Family Name*
Address*
Post Code*
Home Phone*
Work Phone
Mobile
Email*
Name 2
First Name
Family Name
Address
Post Code
Home Phone
Email
Name 1 (please tick as applicable)
Working full-time Working part-time SDN staff member Stay at home parent Studying
Other
Hours at work per day
Name 2 (please tick as applicable)
Full-time
Other (state days required)
Month and year childcare is required
The demand for childcare sometimes exceeds supply. When this happens it is important for services to allocate places to those families with the greatest need for childcare support. The Australian Government has Priority Access Guidelines for allocating places in these circumstances. To help us determine priority of vacancies, please indicate if the information below applies to you.
Is your child Aboriginal or Torres Strait Islander? NoYes
Does your child have a disability? NoYes
Have you been referred by an agency? NoYes
Are you a Health Care Card holder? NoYes
Are you a single parent? NoYes
What is your ethnicity/cultural background?
I agree to notify the Centre Director immediately if I no longer require a place for my child at the Centre and wish to be removed from the waiting list, or if any of the above information changes in any way. (Failure to do so may result in loss of position on waiting list.)
I agree to the above condition
SDN Children’s Services has a firm commitment to protecting the privacy of its clients. SDN complies with the national privacy principles set out in the Privacy Amendment (Private Sector) Act 2000. For more information please refer to the SDN Privacy Policy available at your centre. Personal information collected on this form is for the purpose of contact and establishing priority of access.
