Childs name

First Name

Last Name

Sex

MALE

FEMALE

Date of Birth *

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

Does your child meet any of the following criteria?

Attended a 3-Year-Old program through Early Start Kindergarten or Access to Early Learning

Is you child known to Child FIRST, Child Protection or family services

Have you been referred by a Maternal and Child Health nurse, support service or Out of Home Care provider

Does your child already attend / has attended a Playgroup / other funded kindergarten program?

Yes

No

Parent / Guardian name 1

First Name

Last Name

Mobile / Phone

(###)

###

####

Parent / Guardian 2

First Name

Last Name

Mobile / Phone

(###)

###

####

DET provides a fee subsidy for eligible families. Please indicate if you are eligible for one of the following concessions, or meet one of the following criteria (supporting documentation will need to be sighted on commencement at Taraleigh Steiner Kindergarten):

Health care card

Pensioner concession card

DVA White or Gold card

Refugee and Special Humanitarian Visas (200-204, 786 or 866)

Bridging visas for any of the above Refugee or Asylum Seeker visas

Triplets or Quadruplets

Aboriginal or Torres Strait Islander

Preference for group and starting year:

Younger group: Your child must turn 3 by 30th April in the year they attend. (Conditions apply to attendance before turning 3)

Older group: Your child must turn 4 by 30th April in the year they attend.

Registration Fee Payment of $50 is to be provided with Application Form.

Bendigo Bank: A/C Name: Taraleigh Steiner Pre-School BSB: 633000 A/C Number: 128086816 Trans Reference: ‘APP FEE’ Surname

EFT Transfer

Date

MM

DD

YYYY

Date 2

MM

DD

YYYY

I give permission for this information to be shared with Taraleigh Steiner Kindergarten and Playgroup for the purposes of accessing kindergarten and, if applicable, applications for State funding necessary to provide additional support for my child’s participation. I give permission for this data to be anonymised, de-identified and aggregated (and shared with identified third parties) to help forecast future needs and help to improve the service. I declare that all of the information provided is true and correct. *

Agree