Casa Piccola Waiting List Application Form NEW

Casa Piccola Playgroup - Waiting List Application Form
This application is for your child to be placed on the waiting list for the Casa Piccola Toddler. Lodgement of this form does not guarantee your child a place in Casa Piccola.

Before you complete the form please ensure you have read the Casa Piccola information available on the website.

A separate waiting list application form is required for each child.

Please note : This application is for the Casa Piccola Playgroup only. There is a separate application form for the Children's House kindergarten programme.

Privacy information : Brunswick Montessori Children's House Inc collects information for administration purposes only and no information will be disclosed to any other party except as required by law.
I acknowledge that Casa Piccola is for children aged between 18 months and 3 years ONLY*
Family Information
The person completing this form (Adult 1) is considered the primary contact for the Child and Children’s House will use this information to inform you when a place in Casa Piccola becomes available. Please note: It is the responsibility of the parent/guardian to ensure Children’s House has current contact details.
Adult 1 *

First NameLast Name
Relationship to the child*

MotherFatherGuardianOther
Will this adult be ATTENDING with the child?*

YesNo
Phone*
E-mail*

Confirmation Email
Address*

Street Address

Street Address Line 2

CityState

Post CodeCountry
Adult 2

First NameLast Name
Relationship to the child

MotherFatherGuardianOther
Phone*
Child Information
Full Name*

First namesLast Name
Gender

MaleFemalePrefer not to stateOther
Birth Date*

MonthDayYear
Address (if different to home address provided above)

Street Address

Street Address Line 2

CityState

Post codeCountry
Country of birth*
Language(s) spoken at home*
Is an interpreter required?*

YesNo
Registering for Casa Piccola in year*

202420252026
How did you hear about the Casa Piccola Playgroup?*

Children's House WebsiteMontessori Australia Foundation WebsiteWord of MouthPlaygroup VictoriaInternet SearchOther
Children with additional needs

Children’s House is committed to providing a quality environment for all children including those with additional needs, allergies, health concerns or any other special requirements. Please answer the following questions:
Does you child have an ALLERGY (requiring medical support ie. asthma, hay fever, food related anaphylactic allergies)?*

YesNo
If yes, please provide specific details INCLUDING treatment / medication required:
Does you child have an INTOLERANCE?*

YesNo
If yes, please provide specific details INCLUDING treatment / medication required:
Does you child have additional needs (i.e ASD, disability etc) that we should be aware of?*

YesNo
If yes, please provide information here:
Session preference
Casa Piccola is held on Friday morning 9:00-10.30am, Friday late morning 11.00am-12.30pm and Saturday morning 9:00-10:30am. Please indicate your preference*

Friday 9amFriday 11amSaturday 9amNo preference - first available vacancyOther
Waiting List Fee
This form needs to be accompanied by payment of the $50 waiting list fee before your child can be placed on the waiting list.

This is an administrative fee and cannot be refunded.

A separate waiting list application form is required for each child.

Please use your child's full name in the account description, so we can keep track of your payment and issue a receipt.

Payment details
Account Name: Brunswick Montessori Children's House Inc.
Bank: Bendigo Community Bank Strathmore
Account No: 147 013 122
Account BSB: 633 000
I have read the Casa Piccola information on the BMCH website*

Yes
The Waiting List Fee has been/will be paid to Children's House*

YesNo
I am aware that Casa Piccola is a stand alone program and is NOT connected to the preschool program (Children's House). I acknowledge that if I wish to apply for the preschool, it is a separate wait-list and application process.*

YesNo
Should be Empty:

Casa Piccola Playgroup - Waiting List Application Form

Family Information

Child Information

Children with additional needs

Session preference

Waiting List Fee