CHILD INFORMATION
Child #1Child’s first name: Child’s family Name:
Child’s date of birth: Male or Female:
Child #2
Child’s first name: Child’s family Name:
Child’s date of birth: Male or Female:
Child #3
Child’s first name: Child’s family Name:
Child’s date of birth: Male or Female:
Please note: We do not accept unborn children on the wait list.
PARENT INFORMATION
Parent #1Title: Name:
Address:Postcode:
Home Phone:Work Phone:Mobile:
Email address:Fax:
Parent #2
Title: Name:
Address:Postcode:
Home Phone:Work Phone:Mobile:
Email address:Fax:
Please note: If your information changes at any time (address/phone number) please inform the administrator.
Continued Overleaf
PARENT INFORMATION
Do you work or study in the City of Kingston? Yes No Are you employed by the City of Kingston? Yes No
Is your child of Aboriginal or Torres Straight Islander descent? Yes No
Do you require an interpreter? Yes No
Parent #1. What is your first language?
Parent #2. What is your first language?
Is your child currently enrolled at another child care centre? Yes No
Is your child currently on any other waiting lists within the City of Kingston? Yes No
(Please note the above information is only a statistical collection and will not effect your place on our waiting list)
DAYS OF CARE / EDUCATION REQUIRED(tickapplicable)
Monday Tuesday Wednesday Thursday FridayAre these days flexible? Yes No Do you have any flexibility to start with less days? Yes No
How many days of care per week do you require? 1 or 2 or 3 or 4 or 5 (Please circle one number only)
REASON FOR CARE(tick all applicable)
Single Parent Yes No Parent working / studying / training
Parent 1 Yes No
Parent 2 Yes No
Do you require an interpreter? Yes No
Parent seeking work Yes No
Does your child have a diagnosed disability, any food allergies or special requirements?Yes No
CENTRE PREFERENCE
Please only tick the centre(s) you are prepared to attend. If you choose more than one centre, please put in the order of your preference. Tick if you have visited the Centre(the option to visit the Edithvale Family & Children’s Centre and the Parkdale Family & Children’s Centre is not yet available).
2014 ONLY2015 ONLY
Number in order Number in order
of PreferenceVisited Centreof PreferenceVisited Centre
____ / Carrum Child Care Centre9 Dyson Road, Carrum VIC 3197
Phone: 9773 1252 / / ____ / Carrum Child Care Centre
9 Dyson Road, Carrum VIC 3197
Phone: 9773 1252 /
____ / Lochiel Avenue Child Care Centre
6 Lochiel Avenue, Edithvale, VIC 3196
Phone: 9772 1560 / / / ____ / Edithvale Family & Children’s Centre
Edithvale Road, Edithvale Vic 3196
Phone: TBA /
____ / Stawell Street Child Care Centre
4 Stawell Street, Mentone, VIC 3194
Phone: 9584 5169 / / / ____ / Parkdale Family & Children’s Centre
Warren Road, Mordialloc Vic 3195
Phone: TBA /
____ / Mountview Child Care Centre
3 Mountview Avenue, Parkdale, VIC 3195
Phone: 9584 5169 /
Information provided for this form will be used for the purpose of allocating vacant child care places at a City of Kingston Child Care Service
Personal information collected by Council is used for municipal purposes as specified in the Local Government Act 1989. The personal information will be held securely and used solely by Council for these purposes and/or directly related purposes. Council may disclose this information to other organisations if required or permitted by legislation. The applicant understands that the personal information provided is for the above purpose and that he or she may apply to Council for access to and/or amendment of the information. Requests for access and/or correction should be made to Council's Privacy Officer. A full copy of our Privacy Policy may be obtained from the Kingston website: or from one of our Customer Service Centres.