Early Childhood Services Waiting List Application Form

Early Childhood ServicesWaiting List Application FormBanyule City Council’s Early Childhood Services are:Joyce Avenue Children’s Centre1 Joyce Avenue Greensborough 3088 03 9434 6098Morobe Street Children’s Centre229 Oriel Road Heidelberg West 3081 03 9459 8998St Hellier Street Children’s Centre95 St Hellier Street Heidelberg West 3081 03 9459 5227OFFICE USE ONLY:Application Number:Child 1: Child 2:Child 1 NAR:Child 2 NAR:Parent/Guardian NAR:Your child care preference(s): (Please number in order of preference 1.2.3)Joyce Avenue Children’s Centre:Morobe St Children’s Centre:St Hellier St Children’s Centre:Do you have a child already in care at this centre? Yes NoDo you have a child already in care at this centre? Yes NoDo you have a child already in care at this centre? Yes NoAustralian Government Priority Access Guidelines:Why do you require care? Please tick the appropriate box.First Priority: a child at risk of serious abuse or neglect;Second Priority: a child of a single parent/s who satisfies the work/training/study testThird Priority: any other child.________________________________________________________________________________When do you need care to commence? / /________________________________________________________________________CHILD 1 DETAILS: (BLOCK LETTERS PLEASE)Surname: _________________________ Given Names: ______________ ____________Date of Birth: ____/____/____ Male or Female (please circle)Does your child identify as Aboriginal or Torres Strait Islander Yes NoCountry of Birth: _________________Language spoken at home: ________________ADDITIONAL NEEDS/REQUIREMENTS:(Does your child have any additional needs/requirements? Yes NoComments:______________________________________________________________________________________________________________________________Children’s Services 10608 ECS Waiting List Application InfoVision Ref:OptionalLast Amended:06.06.2013Page 1 of 3

CHILD 2 DETAILS: (BLOCK LETTERS PLEASE)Surname: _________________________ Given Names: _____________ _____________Date of Birth: ____/____/____ Male or Female (please circle)Does your child identify as Aboriginal or Torres Strait Islander Yes NoCountry of Birth: _________________Language spoken at home: ________________ADDITIONAL NEEDS/REQUIREMENTS:Does your child have any additional needs/requirements? Yes NoComments: _____________________________________________________________________________________________________________________________PARENT/GUARDIAN DETAILS:Mr/Mrs/Ms: Surname: _________________________Given Names: _____________________Date of Birth ___/___/___ Address:_________________________________________________________________________________________ Postcode_____________Telephone: (H) _________________ (Mob) ____________________ (W)_____________________Country of Birth: ________________Language spoken at home: ________________Will you require an interpreter? Yes NoEmail Address: ______________________________________________Do you give permission for Council to contact you via email? Yes NoHow did you hear about the services? Council Events Friends/Family Maternal Child Health Website Other (please state) ______________________________Children’s Services 10608 ECS Waiting List Application InfoVision Ref:OptionalLast Amended:06.06.2013Page 2 of 3

Days of Care Required:(Please tick)Monday: Are your days flexible? Yes NoTuesday:Wednesday:Thursday:Friday:Comments: ______________________________________________________________________________________________________________________________________________________________________________Council Contact & Accessibility Options:Email: earlyyears@banyule.vic.gov.auTelephone: 03 9490 4222 Fax: 9499 9475SMS Text Message Information(Through Access Officer)Audio Loop(At Customer Service Centres)Interpreting Service(Arranged Through Chosen Service)Bionic Ear(Arranged through Council)Council respects all personal and confidential information you give and will do everything possible toprotect information from unauthorised access, loss or misuse.Information collected from you is required for the delivery of Council Services in accordance withCouncil’s powers, functions and purposes under the Local Governments Act 1989 and other relevantlegislation. It may also be used by Council to conduct research and customer satisfaction surveys sothat we may better understand community needs and can improve service delivery. Should youneed to change or access your personal details, please contact Council on 03 9490 4222.I ______________________________________ (please print) understand that the informationprovided above will be used in accordance with relevant legislation and declare that this informationis correct to the best of my knowledge.Signature: __________________________________________ Date: ____/____/______Please return this form to:Banyule Early Childhood ServicesPO BOX 51 Ivanhoe VIC 3079Email: earlyyears@banyule.vic.gov.auChildren’s Services 10608 ECS Waiting List Application InfoVision Ref:OptionalLast Amended:06.06.2013Page 3 of 3