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CHILD INFORMATION  
Family Name: Sex: Male     Female
Given Name: Date of Birth:
Home Address: Usually Called:
Post Code: Ethnic Origin (Optional): :
Country of Birth: Religion (Optional):
Arrived in Australia: Languages Spoken: (Optional):

CHILD'S PARENTS/GUARDIANS INFORMATION  
Mother/ Guardian 1 Father/ Guardian 2:
Name: Name:
Address: Address:
Occupation: Occupation:
Ethnic Origin: Ethnic Origin:
Language spoken: Language spoken:
Country of Birth: Country of Birth:
Religion (Optional): Religion (Optional):
Home: Home:
Work: Work:
Mobile: Mobile:
Email: Email:
Does the child live with Parent / Guardian: Yes     No

SPECIAL REQUEST  
Court Orders relating to the child: Yes     No
Centre will copy original court orders for files

MEDICAL / HEALTH  
Does the child have any medical conditions and need (e.g. allergies, epilepsy, diabetes, etc...)
Which are relevant to the children's services? Yes     No
If Yes, the following management procedure are to be followed:
Does the child have any dietary restrictions? Yes     No
If Yes, the following restrictions apply:

PRIOR CHILDCARE ARRANGEMENT  
At Home: Relative / Guardians: Playgroup: Family Day Care:
Long Day Care/ Kindergarten: If Yes name of the centre /s:

PLACE REQUESTED  
Full Time: Part Time: Intended Start Date:
MON:     TUE:     WED:     THU:     FRI:             DATE:
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