Child's First Name*

Child's Last Name*

Gender* Gender* Male Female

Date of Birth*

Proposed Booking Details* Proposed Booking Details* Monday Tuesday Wednesday Thursday Friday

From Date

To Date

Number of Weeks

Access Guidelines* Access Guidelines* Child at risk of abuse or neglect OR family in crisis Child of a single parent who satisfies, or of parents who both satisfy, the work/ training/study test Any other child Children in an Aboriginal or Torres Strait Islander family Children in a family which includes a disabled person Children in a family which includes an individual whose adjusted taxable income does not exceed the lower income threshold, or who or whose partner is on income support Children in a family from a non-English speaking background Children in a socially isolated family Children of a single parent family

Parent/Carer's Name*

Contact Phone Number* Home, Work or Mobile

Address*

Email*

Relationship to Child*

Primary Language*

How Did You Hear About Us? How Did You Hear About Us? Through The Department For Education Word of Mouth Social Media Other

If Other, Please specify below