Enrolment Waiting List Application

ENROLMENT WAITING LIST APPLICATION

Please complete the following form to enroll your child in our waiting list program.

Your Child’s Details

Expected Year of Enrolment *

Surname *

Given Names *

Date of Birth *

Place of Birth *

Gender *

Female

Male

Aboriginal Australian or Torres Strait Islander? *

Yes

No

Holder of a Commonwealth Benefits Health Care Card? *

Yes

No

Immunisation Status *

AIR History Form

AIR Medical Exemption

Parent/Guardian Details

Surname *

Given Name/s: *

Email:

Phone Number: *

Surname: *

Given Name/s: *

Email:

Phone Number: *

Address (Child’s primary residence): *

Enrolment Details

Please list any siblings. Please tick the box if they have previously attended Periwinkle.

Name of sibling:

DOB:

Previously attended Periwinkle

Yes

Name of sibling:

DOB:

Previously attended Periwinkle

Yes

Name of sibling:

DOB:

Previously attended Periwinkle

Yes

Will your child be attending any other form of care whilst at Periwinkle? If yes, please detail where and no. of days attending. *

Preferred Days

Please rank your preferred days for your child to attend Periwinkle. Please note that your child must attend 5 days a fortnight on consecutive days and preference will be given to 4-year old’s. That is children turning 4 before 31st July in the year enrolling.

Please Indicate preferred days *

Monday & Tuesday alt Wednesday

Thursday & Friday alt Wednesday

Account name: Periwinkle Preschool
BSB: 082-489
Account #: 570447998

Please tick this box to indicate you have transferred the $30 waiting list application fee. *

Yes

Name: *

Signature: *

Date: *