Waiting List Form

Applicant's Name
Applicant's First Name
Applicant's Last Name
Relationship to Child
(ie. parent, gaurdian, etc.)
Child's Name M or F DOB
First Name
Surname
Address
Contact Email:    
       
Mother's Name: Father's Name:
Address (if different
from above)		 Address (if different
from above)
Phone: Home Phone: Home
Mobile: Mobile:
Email (if different from above): Email: (if different from above)
Phone: Work Phone: Work
Occupation: Occupation
Days of Work M Tu W Th F Days of Work M Tu W Th F
Actual Days Required (Check days required) M Tu W Th F

If you require less than 4 days per week, are you prepared to accept any days that are allocated?
Yes, I would be happy with whatever days are available.
No, I specifically require the days circled above.
Which Centre do you wish to attend? (Check all that apply)
Alunga Child Care Centre - Albion Park Rail
Clipper Road Children's Centre - East Nowra
Hospital Hill Preschool and Occasional Care Centre - Wollongong
Keiraview Child Care Centre - Wollongong
Sanctuary Point Children's Centre - Sanctuary Point
Short Street Preschool and Occasional Care Centre - Corrimal
Smith Street Child Care Centre - Wollongong
The Basin Preschool - Sanctuary Point
Wallaroo Child Care Centre - Shellharbour
Warilla Preschool and Occasional Care Centre - Warilla
Starting Date Required OR As soon as possible
Priority of Access The answers you give here will determine your priority rating.
PRIORITY 1
Is the child at risk of serious abuse or neglect? Yes No If you answer YES you will be required to provide documentation of this.
PRIORITY 2
Are you a single parent who is working? Yes No If you answer YES you will be required to provide proof of employment when your child is accepted for enrolment.
Are you a family with both parents working? Yes No If you answer YES you will be required to provide proof of employment when your child is accepted for enrolment.
Are you studying for future employment? Yes No If you answer YES you will be required to provide proof of enrolment in an approved course.
Are you actively seeking employment? Yes No If you answer YES you will be required to provide written proof of your attempts to obtain employment. (Eg, registration with Centrelink) when your child is accepted for enrolment.
PRIORITY 3
Are you a single parent at home? Yes No
Does you child have special needs? Yes No
Does you child have special cultural needs? Yes No
Does either parent have special needs? Yes No
If you have answered YES to any of the above, please explain the nature of the needs.
I understand the priority of access conditions outlined above and agree to notify the centre should my circumstances change.
Is your child Aboriginal Torres Strait South Sea Islander?
Is your child from a culturally and linguistically diverse background?  Yes No
If yes please provide details:
Does your child have: If yes please provide details
Medical Condition Yes No
Asthma Yes No
Disability Yes No
Allergies Yes No
Special Dietary Needs Yes No
Sibling on waiting list
DOB
First Name
Surname



     
MARKETING INFORMATION

Please indicate how you found out about the service (optional)
Recommended by a friend Location Word of mouth Website
Child Care Hotline Telephone Book Other

I understand that submission of this form does not guarantee a place in my chosen centre.
(IACC staff will be in contact if further information is required or when a place is available.)