Name of Parent/Guardian

E-mail address

Address ........ ............................................................................................................Suburb

State NSW VIC QLD WA SA TAS ACT NT Postcode

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 then $200/week in child care fees ($61p.a./child): 3 day deferral period I pay less then $200/week in child care fees ($120p.a./child): 2 day deferral period I pay more then $200/week in child care fees ($91p.a./child): 3 day deferral period I pay more then $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