Parent's Name*

Child's Name*

Child's Date of Birth*

Address*

Email*

Phone*

In Catchment Area* (Click on link above to see catchment areas) In Catchment Area* (Click on link above to see catchment areas) Yes No

Please Select One or More* Please Select One or More* Special Needs Aboriginal Guardian of the Minister Not Applicable

Please Describe Your Child's Special Needs

Siblings Previously at Centre* Siblings Previously at Centre* Yes No

Preferred Days* Preferred Days* Monday/Tuesday Wednesday/Thursday

Intended School (if known)

Kindergarten Start Date*

Eligible Preschool Year*

Additional Information