Port Lincoln Children's Centre - Department for Education

Part One: Child's Details

Child's Name *

Date of Birth *

Centrelink Child Reference Number *

Residential Address of Child *

Address Line 1

City

State / Province / Region

Postal Code

Country

Part Two: Parent 1 Details

Parent 1 / Carers Name *

Date of Birth of Parent 1 *

Centrelink Reference Number *

Residential Address of Parent 1 *

Address Line 1

City

State / Province / Region

Postal Code

Country

Postal Address of Parent 1 (if different from above)

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Parent 1 Phone Number

Parent 1 Mobile

Parent 1 Email Address *

Is Parent 1 currently:

Working
Studying
Parenting
Seeking Work

Your details (please tick any that apply)

Parent 1 Employer Name *

Parent 1 Work Address *

Address Line 1

City

State / Province / Region

Postal Code

Country

Parent 1 Work Phone Number

Parent 1 Days and Hours of Work

Parent 1 Place of Study *

Parent 1 Days and Hours of Study

Part Three: Parent 2 Details

Parent 2 / Carers Name *

Residential Address of Parent 2 (if different from above)

Address Line 1

City

State / Province / Region

Postal Code

Country

Parent 2 Phone Number

Parent 2 Mobile

Is Parent 2 currently:

Working
Studying
Parenting
Seeking Work

Your details (please tick any that apply)

Parent 2 Employer Name *

Parent 2 Work Address

Address Line 1

City

State / Province / Region

Postal Code

Country

Parent 2 Work Phone Number *

Parent 2 Days and Hours of Work

Parent 2 Place of Study *

Parent 2 Days and Hours of Study

Part Four: Application Details

Please indicate the times and days you prefer care

Monday start time

Monday end time

Tuesday start time

Tuesday end time

Wednesday start time

Wednesday end time

Thursday start time

Thursday end time

Friday start time

Friday end time

Does your child have an additional needs eg speech / language; occupational therapy, developmental delays? *

Yes
No

Does the child identify as an Aboriginal or Torres Strait Islander? *

Yes
No

Disclaimer *

I wish to apply for placement as detailed above at the Port Lincoln Children's Centre Inc. I understand that to maintain this place on the waiting list, I/we need to contact the Centre at least every two months to confirm our continuing interest. Not doing so will mean the deletion of this application from the waiting list.
I understand that I must contact centrelink and apply for child care subsidy to be placed on our waiting list.

How did you find out about this service?

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