Child Care APPLICATION FORM Child Care Centralised Waiting List This should be read in conjunction with the Child Care Information Sheet. For further information go to:
www.darebin.vic.gov.au/childcare
The City of Darebin collects information for the purpose of registering your child for the Child Care Waiting
List. The information will be used for administration purposes and to inform the Child Care Centre of your
contact details. No information will be disclosed to any other party except as required by law
‫ سوف ُتستخدم المعلومات ألغراض إدارية وسوف ُتسلم إلى مركز رعاية الطفل‬.‫تقوم مدينة داريبن بجمع المعلومات لغرض تسجيل طفلك في قائمة االنتظار لرعاية األطفال‬
.‫بمجرد قبول أحد األماكن‬
.‫لن يتم اإلفشاء عن أي معلومات إلى أي طرف ثالث باستثناء بحسب ما ينص عليه القانون‬
戴瑞賓市議會就托兒服務輪候名單登記收集資料。所收集得的資料將會作行政用途，並會在孩子獲提供托兒服務時交給托
兒中心。
除法律要求外有關資料不會對外披露。
Ο ∆ήμος του Darebin συλλέγει πληροφορίες για το σκοπό εγγραφής του παιδιού σας στην Λίστα Αναμονής Παιδικής
Φροντίδας. Οι πληροφορίες θα χρησιμοποιηθούν για σκοπούς διοίκησης και θα δοθούν στο Κέντρο Παιδικής Φροντίδας
άπαξ μια θέση έχει γίνει αποδεκτή. Καμία πληροφορία δεν θα αποκαλυφθεί σε άλλα μέρη εκτός όπως απαιτείται από το
νόμο.
La City di Darebin raccoglie informazioni allo scopo di registrare vostro figlio nella lista d’attesa per gli asili infantili. Le
informazioni saranno usate a scopo amministrativo e verranno comunicate all’asilo quando avrete accettato un posto.
Nessuna informazione verrà divulgata a terzi eccetto laddove richiesto da disposizioni di legge.
Општината Даребин ги собира информациите со цел да го регистрира вашето дете на листата за чекање за
згрижување на детето. Овие информации ќе се користат за административни цели и ќе се дадат на Центарот за
згрижување на деца штом ќе се запише. Никакви информации нема да бидат дадени на било кого освен ако
треба според законот.
Thành Phố Darebin thu thập thông tin để đăng ký con của quý vị vào Danh Sách Chờ Chăm Sóc Trẻ Em (Child Care
Waiting List). Thông tin này sẽ được sử dụng cho mục đích quản lý hành chính và được cung cấp cho Trung Tâm Chăm
Sóc Trẻ Em (Child Care Centre) ngay khi được chấp nhận. Không có bất cứ thông tin nào được tiết lộ cho bên thứ ba trừ
khi pháp luật yêu cầu.
Please return completed application form to:
Darebin Family and Children
Child Care Centralised Waiting List
P.O Box 91
Preston VIC 3072
Or in person, to any customer service centre below:
Centre
Preston Customer Service Centre
Address
Hours
274 Gower Street, Preston
8.30am - 5.00pm Monday to Friday
Northcote Customer Service Centre
32-38 Separation Street,
Northcote
8.30am - 5.00pm Monday to Friday
Northland Customer Service Centre
50 Murray Road, Northland
Shopping Centre
8.30am - 5.00pm Monday to Friday
9am - 12pm Saturday
Reservoir Civic Centre
23 Edwardes St, Reservoir
8.30am - 5.00pm Monday to Friday
1.
Child Care Application Form
•
To commence child care a child must be between 3 – 6 months.
(the minimum age varies between centres)
•
Completion of this application form does not guarantee placement.
•
Information contained in this form is strictly confidential and will only be used in the child care
application process.
Please complete one form for each child:
Child’s details:
Surname: ______________________________________________________________________
Given Names: __________________________________________________________________
Date of Birth: ___________________________________________________________________
Male
Female
*Child CRN:______________________
Child care preferences:
Please provide up to 4 preferences in order of preference where you are prepared to accept a place for
your child if offered.
Visited centre (tick box)
1._________________________________________________________
2._________________________________________________________
3._________________________________________________________
4._________________________________________________________
Please contact me when other centres become available
Yes
No
I/we will wait for one of our nominated centres
Yes
No
Does your child have a sibling who is currently enrolled in your preferred (No.1 preference) child care
centre?
Yes
Name of child:________________________________________________
No
START DATE REQUIRED FOR CARE:____________________________
Which day/s do you need child care (please tick)
Monday
Tuesday
Thursday
Friday
Wednesday
Full Time
Are these days flexible?
Please note: Some centres require a minimum of two days
Yes
No
Any additional comments:
______________________________________________________________________________________
______________________________________________________________________________________
* CRN – each parent and child registered with Centrelink is issued with a ‘Customer Reference Number’
2.
Parent/legal guardian details:
Parent/legal guardian 1:
Mr/Mrs/Ms/Miss/Dr/Other (please circle)
Surname:_____________________________________________________________________
Given name:___________________________________________________________________
Relationship to child:_____________________________________________________________
+ Residential address:___________________________________________________________
Suburb:__________________________________ Postcode:____________________________
Telephone: Work____________Home______________Mobileª_______________________
Email:________________________________________________________________________
Language/s spoken at home:______________________ Country of Birth:__________________
Interpreter required:
No
Yes
Preferred contact method:
Email
Mail
Parent CRN*:_______________________________
Postal address (if different to above):
_____________________________________________________________________________
Parent/legal guardian 2:
Mr/Mrs/Ms/Miss/Dr/Other (please circle)
Surname:_____________________________________________________________________
Given name:___________________________________________________________________
Relationship to child: ____________________________________________________________
+ Residential address:___________________________________________________________
Suburb:______________________________
Postcode:_____________________________
Telephone:Work______________Home______________Mobileª______________________
Email:_________________________________________________________________________
Language/s spoken at home:______________________ Country of Birth:___________________
Interpreter required
No
Yes
Mail
Preferred contact method:
Email
Parent CRN*:_________________________
Postal address (if different to above):
________________________________________________________________________________
Are there any specific needs as parents/guardians that will make it difficult to get your child to Child Care?
(e.g. a disability or medical condition)
Please note: If you respond Yes, Please provide supporting documentation
Yes
No
Please provide details: _____________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
3.
Additional Information
Why do you require Child Care? (Places will be allocated in accordance with the Commonwealth Priority of
Access Guidelines, please tick all that apply)
Family linked to Family Services (Please attached letter of support from your agency)?
Yes
No
Yes
No
Yes
No
Child of a single parent who satisfies, the work/training/study test under section 14 of the
Family Assistance Act
Name of business/institute:________________________________________________
Work/Study address:_____________________________________________________
Telephone Number :___________________________________________________
Child of a two parents who satisfies, the work/training/study test under section 14 of the
Family Assistance Act
Parent/Guardian 1:
Name of business/institute:_________________________________________________
Work/Study address:______________________________________________________
Telephone Number :____________________________________________________
Parent/Guardian 2:
Name of business/institute:_________________________________________________
Work/Study address:______________________________________________________
Telephone Number :_____________________________________________________
Child in a family which includes a person with a disability (For example; receipt of carers allowance)
Yes
No
Family requesting social contact or respite care?
Yes
No
The child is currently accessing a program at the same centre?
Yes
No
Name of centre:__________________________ Phone:____________________________
Is your child of Aboriginal or Torres Strait Islander descent?
Yes
No
Are you a resident of Darebin?
Yes
No
4.
Additional Needs:
Does your child have any additional needs or a disability?
Yes
No
If Yes, please provide details (Diagnosis or specific additional need)
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Does your child attend or access any specialist services?
(e.g. Early Intervention, Speech Therapy etc)
Yes
No
If Yes, please list: ________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Are you on the waiting list to access any specialist services?
Yes
Please specify which type of service?
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
5.
No
Check List
(please tick the box):
1. Supporting documentation (photocopied) and attached to this form
Proof of child’s age such as a copy of the child’s Extract of Birth Certificate, passport, Maternal and
Child Health Record or letter from family services
Proof of Darebin residency such as rates notice/tenancy agreement or current utility account
Letter from family support services or intervention services
Document confirming sibling’s attendance at preferred child care service (for example, receipt of
child care fees paid with sibling’s name.)
Documents confirming proof of child in a family which includes a person with a disability (for
example; receipt of carers allowance)
2.
I have completed all details on the Application Form
Incomplete applications cannot be accepted and will be returned
3. Please ensure this document is sent or delivered to:
Darebin Family and Children
Child Care Centralised Waiting List
P.O Box 91
Preston VIC 3072
Or deliver in person to any customer service centre below:
Centre
Address
Hours
Preston Customer
Service Centre
274 Gower Street, Preston
Northcote Customer
Service Centre
32-38 Separation Street,
Northcote
Northland Customer
Service Centre
50 Murray Road, Northland 8.30am - 5.00pm Monday to Friday
Shopping Centre
9am - 12pm Saturday
Reservoir Civic
Centre
23 Edwardes St, Reservoir 8.30am - 5.00pm Monday to Friday
8.30am - 5.00pm Monday to Friday
8.30am - 5.00pm Monday to Friday
I hereby declare all information provided on this form to be true and accurate
Signature of parent/guardian: ____________________________________________________
Name: ________________________________________ Date: _________________________
6.
Darebin Early Childhood Centres participating in Darebin’s Child Care
Centralised Waiting List process
Child Care Centre List
Contact services directly to organize a time to visit.
(Please retain this section for your records)
Please note: All these child care centres offer a funded kindergarten program.
Name
Address
Phone
Fairfield/ Northcote
2 Oldis Avenue
NORTHCOTE 3070
55 Clifton Street
NORTHCOTE 3070
129 Perry Street
FAIRFIELD 3078
9486 7638
Merri Community Child Care
Centre & Kindergarten
313 St Georges Road
THORNBURY 3071
9416 9227
Raleigh Street Children’s
Centre
28 Raleigh Street
THORNBURY 3071
9484 2440
Darebin Childcare &
Kindergarten Inc.
260 Gower Street
PRESTON 3072
9471 3780
Nara Community Child Care
Northern Melbourne Institute of TAFE
77-91 St Georges Road
PRESTON 3072
9471 9914
Merrilands Children’s Centre
23-25 Ryan Street
RESERVOIR 3073
9460 4674
Darebin Childcare &
Kindergarten Inc.
6-8 Kenilworth Street
RESERVOIR 3073
9469 2226
Annie Dennis Children’s Centre
Clifton Street Children’s Centre
Perry Street Child Care Centre.
9486 3299
9489 2949
Thornbury
Preston
Reservoir
For all other privately management childcare centres within Darebin please visit: www.darebin.org
→ community directory → children services → child care privately managed.
PO Box 91, Preston, Vic 3072 274 Gower Street, Preston, Vic 3072 Tel: (03) 8470 8888 Fax: (03) 8470 8877 TTY (Hearing Impaired): 8470 8470 Multilingual Telephone Line: 8470 8470 Email: [email protected] Website: www.darebin.vic.gov.au 7.