Bountiful Early Childhood Education Centre Waitlist

Note: A place on our waiting list does not guarantee a position at the service.

Child's Name*:

Gender*:

TBC

DOB/Child Due Date:

Preferred Day(s):

Monday

Tuesday

Wednesday

Thursday

Friday

Are you flexible with the days selected above?:

Yes

Preferred Start Date:

Parent/Carer's Name*:

Parent/Carer's Name 2:

Contact No.*:

Contact No.:

Address:

Email Address:

Does your child have a disability, speech delay, additional need (i.e. behavioural concerns) Comments:

Does your child speak English?

What is the main language spoken at home?

Any children in your family who have/or are attending our service? Name(s):

Is your child of Aboriginal/Torres Strait Islander descent and recognised as such by the community?

Any further information which may be of assistance:

Children who are not vaccinated or have not provided vaccination records may be excluded in the event of a vaccine preventable disease. Is your child's immunisation up to date?

Please notify us immediately if any of the above information changes in any way. (Failure to do so may result in loss of position on waiting list). We have a firm commitment to protecting the privacy of our clients. Personal information collected on this form is for the purpose of contact and establishing priority of access only.