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CHILD'S DETAILS

Child’s surname/ family name: *

Child’s given/ first name: *

Date of Birth: *

Gender: * FemaleMale

Child’s nationality: *

Language/s spoken at home: *

Your target start date: *

Your preferred days: * MondayTuesdayWednesdayThursdayFriday

Preferred book in hours: *

Illness/allergies: *

Comments / Requirements:

PARENTS/GUARDIANS

1. Given names: *

Surname/family name: *

Phone (Home):

Phone (Work):

Phone (Mobile): *

Email: *

Relationship to child: *

Address: *

2. Given names:

Surname/family name:

Phone (Home):

Phone (Work):

Phone (Mobile):

Email:

Relationship to child:

Address:

How did you find out about our centre:WebsiteFacebookGoogleFrom someone I knowCountdown notice boardFrom your sandwich board sign (drive by)Other

Other (please specify): *

Privacy Statement

We are collecting personal information on this information slip so we can register your child on our waiting list. We will use and disclose your child’s information only in accordance with the Privacy Act 1993. Under that Act you have the right to access and request correction of any personal information we hold about you or your child.

Date: *