Section 2
SFo8
OFFICE USE ONLY
DET file no.
Agency file no.
Approved:
Yes
No
Awaiting information:
Review date(s):
……../……../……..
……../……../……..
Kindergarten Inclusion Support
Packages – Disability
Application Form (SFo8)
Complete the Kindergarten Inclusion Support plan before this
application form to determine whether or not support additional to
existing resources is required.
Kindergarten Inclusion Support Packages – Disability – Application Form (SFo8)
page 1
You are required to submit 7 copies, comprising the original plus 6
photocopies to:
Regional Advisory Group Convenor
For addresses, see the Guidelines, Information and Application Kit –
Disability
Applications close last day of Term 3
FAXES WILL NOT BE ACCEPTED.
Kindergarten Inclusion Support Packages – Disability – Application Form (SFo8)
page 2
Part 1: Applicant and Child Details
Name of the Children’s Service lodging this application
Phone
Email
Postal address
Postcode
Location address
Postcode
Name of kindergarten teacher completing this form
(in consultation with the Program Support Group)
Name of early childhood teacher for the year the child is
attending the funded kindergarten program (if known)
Is the kindergarten administered by Kindergarten Cluster Management?
Yes 
No 
If yes, provide details of the Kindergarten Cluster Management organisation and authorisation to submit this application
Name
Authorising
Officer
Role
Phone
Email
Address
Postcode
Signature
Date
Has the early childhood teacher previously successfully applied for a Kindergarten Inclusion Support
package?
Yes 
No 
If yes, in what year?
What support was provided?
Specialist training and
consultancy
Yes 
No 
Details
Minor building modifications
Yes 
No 
Details
Additional staffing
Yes 
No 
Details
Have additional attachments been included?
Yes 
No 
If yes, please list
Late application
If late application, date of commencement
If late application, days and times of sessions
Reason for late application
Kindergarten Inclusion Support Packages – Disability – Application Form (SFo8)
page 3
Child’s Details
Family name
Given name
Date of birth
Gender
Male

Yes


Female
Street address
Suburb
Postcode
Email
Local Government Area
In which country was the child born?
Australia  Other 
Other country
Does the child speak a language other than English at home?
(in consultation with the Program Support Group)

No
If yes, please specify the language
Is the child of Australian Aboriginal or Torres Strait Islander origin? (choose only one box)
Yes, Torres Strait Islander
Yes, Aboriginal
Yes, both Aboriginal and Torres Strait Islander
No, neither Aboriginal nor Torres Strait Islander




Has the child previously been supported by a Kindergarten Inclusion Support package?
Yes 
No 
If yes, was the support provided to the kindergarten submitting this application?
Yes 
No 
Will the child be receiving Early Start funding at this kindergarten?
Yes 
No 
Is this application to support this child in a funded program for 4-year-old children in the year prior to
school?If yes, was the support provided to the kindergarten submitting this application?
Yes 
No 
If yes, will this be the child’s second year of a funded program for 4-year-old children prior to school?
Yes 
No 
In the year the child will be attending the funded kindergarten program
Kindergarten Inclusion Support Packages – Disability – Application Form (SFo8)
page 4
Privacy Notice for Parents / Guardians / Carers*
Please read this notice before you complete the application form. You are encouraged to keep this information.
The Department of Education and Training (the Department) will protect your privacy along with the confidentiality and security of personal
information you have provided. We comply with the Information Privacy Act 2000, the Health Records Act 2001 and other relevant Acts.
Why do we ask you for information?
We collect personal information when a kindergarten applies for KIS package to support a child with a disability, developmental delay or
complex medical needs to attend kindergarten. This information is collected to clarify:
 eligibility of the application
 the high support needs of the child identified in the application for KIS package applications needs
 the TYPE of additional supports identified as required by the kindergarten
 the LEVEL of additional supports identified as required by the kindergarten.
Information about your child is collected from you and the people you have approved to be members of your child’s Kindergarten Program
Support Group. This information assists the Regional Advisory Group to make an informed decision about the kindergarten’s eligibility and
support needs.
The Regional Advisory Group has representatives from:



the Department
the non-government organisation which delivers the Kindergarten Inclusion Support packages program
other relevant professionals (Early Childhood Intervention, health and/or education). Refer to Section 9 in the Guidelines, Information
and Application Kit – Disability for information regarding the composition of Regional Advisory Group.
The Regional Advisory Group returns the information about each child to the regional office and the community service organisation
funded to provide kindergarten inclusion support.
Disclosure of information
Some information which does not identify individual children is used to:


analyse and report the performance of the program within, and to, the Victorian State Government.
analyse and improve Department-funded programs for children with disabilities/additional needs.
Security and retention of information
All information about your child is kept secure and confidential. We respect your right to privacy and will only release information about
your child with your written consent via the Program Support Group. However, there are times when we are required by law to disclose
information about your child. In most circumstances we will let you know if we are required to do this. All Department staff handling
information are required by law to respect your privacy. Any information that is not required will be destroyed.
Accessing information
A copy of your application is kept at the Department’s regional office and the organisation funded to provide the Kindergarten Inclusion
Support in your region. This can be made available to you on request. Please refer to Appendices A and B: Guidelines, Information and
Application Kit – Disability for contact information.
If you choose not to tell us something
If you choose not to tell us something that we need to know to make decisions about supports for your child, we may be unable to provide
your child’s kindergarten with the support they seek.
* Any of the following people can sign the Privacy Declaration:

a person with parental responsibility for ‘major long term issues’ as defined by the Family law Act 1975 (Cth)

an officer delegated to exercise the powers and functions of the Secretary of the Department of Health and Human Services
under sections175(1)(b).(2) & (3) of the Children, Youth and Families Act 2005 (Vic).

a carer authorised under a Department of Health and Human Services Instrument of Authorisation to make decisions about
‘major long term issues’ as defined by the Family Law Act 1975 (Cth)
If none of the above people are available, an informal carer may sign this form. An informal carer is a relative or other responsible adult with
whom the child lives and who has day to day care of the child. Informal carers should sign an ‘Informal Carer Statutory Declaration’ to
confirm their status. This is available at www.ccyp.vic.gov.au.
Kindergarten Inclusion Support Packages – Disability – Application Form (SFo8)
page 5
Privacy Declaration by Parents/ Guardians / Carers
Please tick () correct box.
Name of child
I  We  do  do not  approve this application being made by the kindergarten to assist the access and participation
of my child at kindergarten.
I  We  have  have not  given consent to the people listed in Section 2 as members of the Program Support Group.
I  We  have  have not  been given a copy of the Information Privacy Statement that forms part of this application.
Parent/guardian/carer 1
Title
Mr 
Mrs  Ms 
Signature
Name
Date
____ / _____. / _______
Parent/guardian/carer 2
Title
Signature
Mr 
Mrs  Ms 
Name
Date
____ / _____. / _______
Kindergarten Inclusion Support Packages – Disability – Application Form (SFo8)
page 6
Details of Early Childhood Programs Child Attends
For the year prior to the child attending the funded kindergarten program, list the early childhood programs that the
child attends. Include a contact person, phone number and attendance details.
er early c
Details of early childhood programs
Name of early childhood intervention program/service
Contact person
Phone number
Total hours attended by child per week
Other (e.g. Early Start, three year old activity group/child care/occasional care)
Contact person
Phone number
Total hours attended by child per week
Other (e.g. Early Start, 3-year-old activity group/child care/occasional care)
Contact person
Phone number
Total hours attended by child per week
Other (e.g. Early Start, 3-year-old activity group/child care/occasional care)
Contact person
Phone number
Total hours attended by child per week
Kindergarten Inclusion Support Packages – Disability – Application Form (SFo8)
page 7
Details of Early Childhood Programs Child Will Attend
For the year the child will attending the funded kindergarten program, list the proposed early childhood programs that
the child is expected to attend.
Kindergarten Program
Anticipated total available hours per week of a funded kindergarten program for 4year old children in the year prior to school
If applicable, what are the total hours per week of Early Start Kindergarten funding?
Proposed session times the child will attend
Monday
Tuesday
Wednesday
Thursday
Friday
Other early childhood programs (if applicable)
Name of early childhood intervention program/service
Contact person
Phone number
Total hours attended by child per week
Other (e.g. Early Start, three year old activity group/child care/occasional care)
Contact person
Phone number
Total hours attended by child per week
Other (e.g. Early Start, 3-year-old activity group/child care/occasional care)
Contact person
Phone number
Total hours attended by child per week
Other (e.g. Early Start, 3-year-old activity group/child care/occasional care)
Contact person
Phone number
Total hours attended by child per week
Kindergarten Inclusion Support Packages – Disability – Application Form (SFo8)
page 8
Part 2: Details of All Persons Completing
This Application
By signing this form I agree to be a member of the Program Support Group and I declare that to the best of my knowledge this application:

is complete

addresses all relevant guidelines in the Kindergarten Inclusion Support Packages – Disability: Guidelines, Information and Application
Kit

accurately represents the kindergarten program and the developmental abilities and needs of the child.
Name of
parent/guardian/carer 1
Mr 
Mrs  Ms 
Street address
Suburb
Postcode
Home phone number
Mobile
Business phone
Signature
Name of
parent/guardian/Carer 2
Date
Mr
Mrs
_____./ _____./ ______
Ms
Street address
Suburb
Home phone number
Postcode
Mobile
Business phone
Signature
Date
_____./ _____./ ______
Date
_____./ _____./ ______
Date
_____./ _____./ ______
Date
_____./ _____./ ______
Name of professional 1
Service/Agency name
Role
Phone
Signature
Name of professional 2
Service/Agency name
Role
Phone
Signature
Name of professional 3
Service/Agency name
Role
Signature
Phone:
Name of professional 4
Service/Agency Name
Role
Phone
Signature
Date
_____./ _____./ ______
Please copy this page and attach to the application if further details and signatures are required.
Kindergarten Inclusion Support Packages – Disability – Application Form (SFo8)
page 9
Part 3: Eligibility Criteria
Please refer to the checklist indicators in the Kindergarten Inclusion Support Packages – Disability: Guidelines, Information and Application
Kit, which describes the child’s need for support in the following areas.
3.1 (a) Child’s diagnosis/areas of developmental delay
3.1 (b) Child is undergoing continuing assessment by a person with a relevant qualification
3.2 Reasons for support
If the child is eligible under more than one criterion, tick the corresponding boxes. Complete only questions that are relevant.
 Child is at significant risk of injury to self or others (complete 3.3 below)
 Child is extremely restricted in their capacity for movement (complete 3.4 below)
 Child has exceptional support needs requiring immediate medical intervention for life threatening situations (complete 3.5
below).
3.3 Child is at significant risk of injury to self or others
Describe the child’s behaviour that will need to be taken into account by the kindergarten program to ensure that the child i s
included in the program; that he/she and others are safe and the risk of injury is minimised?
When might the child require extra supervision in the kindergarten program? What behaviours are predictable? Are there any
known ‘triggers’ for those behaviours? What works well in managing those behaviours?
3.4 Child is extremely restricted in their capacity for movement
Describe the child’s physical abilities
What equipment will be used by the child to help them move around the kindergarten and participate in the program?
When will the child require assistance to move at the kindergarten?
Give examples of any other support required to help the child to participate in the kindergarten program
3.5 Child has exceptional support needs – medical
Describe the child’s medical condition
What kind of support will the child need at kindergarten?
How often and when will the child require medical intervention at kindergarten?
Give examples of any other support required to help the child’s to participate in the kindergarten program
Kindergarten Inclusion Support Packages – Disability – Application Form (SFo8)
page 10
Section A:
Only to be completed if section 3.5 above has been completed
GENERAL MEDICAL ADVICE FORM for a child with exceptional support needs that
require immediate medical intervention for life-threatening situations
This form is to be completed by the child’s medical practitioner and provides a description of the health condition and
first aid requirements for a child with exceptional support needs. This information will assist the kindergarten in
developing a Child Health Support Plan, which outlines how the kindergarten will support the child’s medical needs.
Name of kindergarten
Child’s name
Date of birth
MedicAlert number
Review date
(if relevant)
Description of the child’s medical condition and recommended support and care
Level of support required
Include how closely this child needs to be supervised and how frequently health support procedures are required
Type of support
Describe health support requirements, including procedures, preparation of equipment, environmental changes,
positioning, and care and transfers
General supervision for safety
For example, observable symptoms that signal staff should stop the procedure
Description of child’s medical sign/symptoms and first aid response
Observable signs/symptoms
First aid response
1.
2.
3.
4.
5.
Kindergarten Inclusion Support Packages – Disability – Application Form (SFo8)
page 11
Privacy Statement
The kindergarten collects personal information so as the kindergarten can plan and support the health
care needs of the child. Without the provision of this information the quality of the health support
provided may be affected. The information may be disclosed to relevant early childhood educators
and appropriate medical personnel, including those engaged in providing health support as well as
emergency personnel, where appropriate, or where authorised or required by another law. You are
able to request access to the personal information that we hold about you/your child and to request
that it be corrected. Please contact the kindergarten directly or FOI Unit on 96372670.
Authorisation
Name of medical
practitioner
Professional role
Contact details
Signature
Date
_____./ _____./ _______
Name of parent/ guardian/
carer 1
Contact details
Relationship to child
Signature
Date
_____./ _____./ _______
Name of parent/ guardian/
carer 2
Contact details
Relationship to child
Signature
Date
_____./ _____./ _______
First Aid
If the child becomes ill or injured at kindergarten, the kindergarten will administer first aid and call an ambulance
if necessary. If you anticipate the child will require anything other than a standard first aid response, please
provide details on the next page, so special arrangement can be negotiated.
Kindergarten Inclusion Support Packages – Disability – Application Form (SFo8)
page 12
Section B:
Only to be completed if section 3.5 above has been completed
CHILD HEALTH SUPPORT PLAN
This plan outlines how the kindergarten will support the child’s health care needs, based on health advice received from the
child’s medical practitioner. This form must be completed for each child with an identified health care need (not including
those with anaphylaxis as this is done via an Anaphylaxis Management Plan, see:
http://www.education.vic.gov.au/ecsmanagement/educareservices/anaphylaxis.htm).
This plan is to be completed by the early childhood teacher, in collaboration with the parent/guardian and members of the
Program Support Group, as appropriate.
This plan should be developed based on medical advice documented on the General Medical Advice Form.
Kindergarten
Phone
Proposed date for review
Describe the complex medical needs identified by the child's medical/health practitioner?
Other known medical conditions
When will the child commence attending kindergarten?
Detail any actions and timelines to enable attendance and any interim provisions
Contact information
Name of parent/ guardian
/carer 1
Mr
Mrs
Ms
Relationship to child
Address
Home phone number
Name of parent/ guardian/
carer 2
Mr 
Mrs 
Mobile
Business phone
Mobile
Business phone
Mobile
Business phone
Ms 
Relationship to child
Address
Home phone number
Name of other emergency
contact (if parent/guardian
not available)
Relationship to child
Home phone number
Medical /Health practitioner contact
Name
Business phone
Kindergarten Inclusion Support Packages – Disability – Application Form (SFo8)
page 13
List ALL those who will receive copies of this Child Health Support Plan
1. Child’s family
2. Other
3. Other
4. Other
The following Child Health Support Plan has been developed with my knowledge and input
Name of
Mr 
parent/guardian/carer
Mrs  Ms 
Signature
Date
_____./ _____./ ______
Name of early
childhood
teacher(or nominee)
Signature
Date
_____./ _____./ ______
Name/s and signature/s of other persons completing this form
Name
Signature
Date
_____./ _____./ ______
Name
Signature
Date
_____./ _____./ ______
Name
Signature
Date
_____./ _____./ ______
Name
Signature
Date
_____./ _____./ ______
Kindergarten Inclusion Support Packages – Disability – Application Form (SFo8)
page 14
How the kindergarten will support the child’s health care needs
Strategy – how will the kindergarten support the child’s health care needs?
Person responsible
Overall support
Is it necessary to provide the support during the kindergarten session? Provide details of this support, and how and when required.
How can the recommended support be provided in the simplest manner, with minimal interruption to the education and care program?
Who will provide the support?
How can the support be provided in a way that respects dignity, privacy, comfort and safety and enhances learning?
First aid
Does the medical information highlight any individual first aid requirements for the child, other than basic first aid? What are they and
where is this information kept?
Do early childhood educators require training in addition to basic first aid training, e.g. staff involved with excursions and specific
educational programs or activities?
What training is required for early childhood educators?
Routine supervision for health-related safety
Does the child require medication to be administered and/or stored at the kindergarten?
Are there any facilities issues that need to be addressed? If so how will this be achieved?
Kindergarten Inclusion Support Packages – Disability – Application Form (SFo8)
page 15
Strategy – how will the kindergarten support the child’s health care needs?
Person responsible
Does the child require assistance by a visiting nurse, physiotherapist, or other health worker? If so, list the contact details.
Who is responsible for management of health records at the kindergarten?
Where relevant, what steps have been put in place to support continuity and relevance of program for the child?
Personal care
Does the medical information highlight a predictable need for additional support with daily living tasks?
Other considerations
Are there other considerations relevant for this health support plan?
Kindergarten Inclusion Support Packages – Disability – Application Form (SFo8)
page 16
Office use only
Date application received
Is this a late application?

Yes
No

Date application directed to
Regional Advisory Group
Date application assessed
by Regional Advisory Group
Outcome of assessment
Eligible


Not eligible
Date
Appeal lodged
Yes
 No

Date
If yes, date appeal finalized
Was the appeal upheld?
(tick one box only)
Yes 
No 
Date
Letters advising outcome of application sent
Kindergarten management

Date
Kindergarten Teacher

Date
Comments
Kindergarten Inclusion Support Packages – Disability – Application Form (SFo8)
page 17