Please note: A separate application form should be completed for each child.

Name of Parent/Guardian:                                                       Email:

Address:


Suburb:                                                                                         State:                                       Postcode:
NSW VIC QLD WA SA TAS ACT NT

Mobile:                                                                                          Home Ph:


Work Ph:                                                                                       Fax:

Name of Child:                                                                            D.O.B.(dd/mm/yyyy):

Name of Child Care Provider:                                                                                                    State:
NSW VIC QLD WA SA TAS ACT NT

Name of Child Care Provider:                                                                                                    State:
NSW VIC QLD WA SA TAS ACT

Name of Child Care Provider:                                                                                                    State:
NSW VIC QLD WA SA TAS ACT NT

Does your child have any pre existing injuries/illness? Yes No

If Yes, provide details below:

How did you hear about us?
Parenting Australia Expo Parenting Australia Website Child Care Magazine Other Internet Family/Friends (Other)    Other:

Please select the category which applies to you:
I pay less than $200/week in child care fees ($61p.a./child): 3 day deferral period I pay less than $200/week in child care fees ($120p.a./child): 2 day deferral period I pay more than $200/week in child care fees ($120p.a./child): 3 day deferral period I pay more than $200/week in child care fees ($170p.a./child): 2 day deferral period

I confirm that the above information is true and correct and I accept the terms and conditions detailed in the policy. Yes No