Office Addresspostal Addressbirralee Childcare Centreinternet

Office AddressPostal AddressBirralee Childcare CentreInternet

1–7 Samantha CourtPO Box 159Ph: 07 3351 4459

Ferny Hills QLD 4055Caboolture QLD 4510

Fees listed are applicable 1 July 2018 – 30 June 2019 ABN:92 967 232 136

Child details:

Surname:
Given name(s):
Home address:
Date of birth: / Gender Male Female

Parent/Guardian details:

Parent/Guardian 1:

Name: / Contact number(s):
Address:
Relationship to child: / Date of birth:
Place of work: / Work phone number:

Parent/Guardian 2:

Name: / Contact number(s):
Address:
Relationship to child: / Date of birth:
Place of work: / Work phone number:

Child information:

Does your child have any special needs?
Primary language spoken at home: / Do you need the assistance of an interpreter? Yes No
When would like care to commence?
Do you require fulltime care? (Monday to Friday) / Yes No
For part time care please select days required? / Monday Tuesday Wednesday Thursday Friday
Do you wish to be contacted if any days become available? / Yes No
How did you find out about Birralee Childcare Centre: / Council phone listing / Yellow pages / Advertisement / Word of mouth
Service Information / Council website / Other

Customer summary:

I/we understand that to maintain this place on the waiting list I/we need to contact the Nominated Supervisor oftheCentre every 6 months to confirm my/our continuing interest. Not doing so will mean the deletion of this application from the waiting list.

This application form will include a: Booking fee of $10.00

Parent/ Guardian:

Name:
Signature: / Date:

Witness:

Signature: / Date:

Privacy statement

Birralee Child Care Centre is collecting your personal information for the purpose of providing a quality child care service. The collection of this information is authorised under the Education and Care Services National Law, the Education and Care Services National Regulations 2011 and the Queensland Kindergarten Funding Scheme. Some of the information may be given to Commonwealth and State authorities for the purpose of validating the services practices.

Office use only
Reason for placement:______
Signature:______Date:______

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