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Gallery 067

Location

Community Centre, 55 Prince Street,
Clarence Town NSW 2321

Hours

8:15 a.m – 3:45 p.m Monday-Friday

during NSW school terms

Closed during school holidays and gazetted public holidays

Contact

ClarencetownDirector@cscommunity.org.au

Phone: 02 4996 4004

Approved Provider

Enquiry Form

"*" indicates required fields

Parent/guardian name*

Email*

Phone*

Child's first name*

Child's date of birth*

MM slash DD slash YYYY

Is your child toilet trained?*

Yes

No

Does your child have any food allergies?*

Yes

No

Does your child have any additional needs?*

Yes

No

Does your child have any medical conditions?*

Yes

No

Preferred start date*

MM slash DD slash YYYY

Please select what days you are interested in*

Monday

Tuesday

Wednesday

Thursday

Friday

Would you like to arrange a tour of the centre?*

Yes

No

What days and times work best for a center tour?*

Any additional information you would like to provide?*

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Waiting List Form

"*" indicates required fields

Child Information

Surname*

Given Name/s*

Date of Birth*

Month

Day

Year

E.D.D*

Sex*

M

F

Languages spoken at home:*

Known disabilities, diagnosis, allergies or illnesses:*

Child Care Requirements

Month Required:

Year Required:

No. Of Days Required:

Tick preferred Day / s:*

Monday

Tuesday

Wednesday

Thursday

Friday

Number Priority (1 being highest priority):*

Monday

Tuesday

Wednesday

Thursday

Friday

Are you flexible with your days:*

Yes

No

Are you flexible with your start date:*

Yes

No

Parent/Guardian Information

Parent/Guardian 1

Parent/Guardian 2

Title / First name:*

Family name:*

Address:*

Home Address Postcode

Address:*

Home Address Postcode

Home Phone:

Work Phone:

Mobile:

Email:

Ethnicity:

Languages spoken:

Are you any of the following:

Working:

Yes

No

Working:

Yes

No

Have a disability:

Yes

No

Have a disability:

Yes

No

Maternity/Paternity leave:

Yes

No

Maternity/Paternity leave:

Yes

No

Of Aboriginal descent:

Yes

No

Of Aboriginal descent:

Yes

No

Studying:

Yes

No

Studying:

Yes

No

Single parent:

Yes

No

Single parent:

Yes

No

Not working:

Yes

No

Not working:

Yes

No

Seeking work:

Yes

No

Seeking work:

Yes

No

Priority Of Access

Please tick the applicable priority of access:*

Both parents or single parent working or studying

Children of parents with a disability / disadvantage

Children at risk of harm

One or both parents at home

Additional Information

It is your responsibility to notify us of any changes to the information supplied. Some changes to circumstances may affect your chances of being offered a placement within our centre. By filling out this form, your child’s name will go on the Waiting List. You will be contacted when a suitable position becomes available. This form does not guarantee that you will be offered a position.

Declaration

The information I have supplied within this form is to the best of my knowledge, true and correct and I will inform the centre if any changes occur.

Check to add signature*

Check to add signature

Date:*

Month

Day

Year

Signature

Please use a mouse or stylus to sign name

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