Select day for enrolment

9:30am - 11:30am

Monday AM

Tuesday AM

Wednesday AM

Friday AM

Name

Parent/guarduan #1

First Name

Last Name

Phone

(###)

###

####

Name

Parent/guardian #2

First Name

Last Name

Phone

(###)

###

####

Childs name

First Name

Last Name

Sex

MALE

FEMALE

Date of Birth (Please enter MM/DD/YYYY) *

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Does your child have special requirements?

Does your child require any additional support due to a disability including intellectual, sensory or physical impairment? Are there any cultural, religious or dietary needs, medical conditions or allergies/sensitivities?

Yes

No

Would you like to authorise another person to bring and participate with your child(ren)?

Yes

No

Name

First Name

Last Name

Would you like to list an alternative emergency contact person?

Yes

No

Name

First Name

Last Name

Why did you choose our playgroup?

Interest in Steiner education

Child at Taraleigh Steiner Kindergarten

Siblings at East Bentleigh Primary school

Referral by family or friend

Live in the local area

Found us on our website

Playgroup Victoria

Date of application (Please enter MM/DD/YYYY)

MM

DD

YYYY