Waitlist

Applicant's Last Name

Applicant's First Name

Relation to Child

Applicant's Email

Child's Last Name

Child's First Name

Gender
—Please choose an option—MaleFemaleOther

DOB

Child's Address

Is your child:

Is your child from a culturally/linguistically diverse background?

Does your child have:

If yes please provide details

Medical Condition

Asthma

Disability

Allergies

Special Dietary Needs

Name

Address

Phone (Work)

Phone (Home)

Mobile

Email

Occupation

Days of Work

Name

Address

Phone (Work)

Phone (Home)

Mobile

Email

Occupation

Days of Work

Actual Days Required

If you require less than 4 days per week, are you prepared to accept any days that are allocated?

Which Centre do you wish to attend? *
ECTARC Alunga Education and Care ServiceECTARC Clipper Road Education and Care ServiceECTARC Jerry Bailey Education and Care ServiceECTARC Keiraview Education and Care ServiceECTARC Sanctuary Point Education and Care ServiceECTARC Short Street Education and Care ServiceECTARC Smith Street Education and Care ServiceECTARC The Basin Education and Care ServiceECTARC Wallaroo Education and Care ServiceWarilla Education and Care Service

Starting Date

Is the child at risk of serious abuse or neglect?

If you answer YES you will be required to provide documentation of this.

Are you a single parent who is working?

If you answer YES you will be required to provide proof of employment when your child is accepted for enrolment.

Are you a family with both parents working?

If you answer YES you will be required to provide proof of employment when your child is accepted for enrolment.

Are you studying for future employment?

If you answer YES you will be required to provide proof of enrolment in an approved course.

Are you actively seeking employment?

If you answer YES you will be required to provide written proof of your attempts to obtain employment. (Eg, registration with Centrelink) when your child is accepted for enrolment.

Are you a single parent at home?

Does you child have special needs?

Does you child have special cultural needs?

Does either parent have special needs?

Additional Comments

Please indicate how you found out about the service (optional)

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