Parent/Caregiver Name:

Parent/Caregiver email:

Phone Number:

Your Residential Address (Street, Suburb, Postcode):

STUDENT NAME:

STUDENT DATE OF BIRTH:

Current school or kindy:

Days attending kindy (if applicable):
MondayTuesdayWednesdayThursdayFriday
Does this student identify as Aboriginal or Torres Strait Islander?
Yes - AboriginalYes - Torres Strait IslanderNo
Are there any custody arrangements in place?
NoYes - Amicable SeparationYes - with Court Order
Please detail any medical needs or diagnosis information:

Any information you wish to add:

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