Form

WILLIAMTOWN PRE SCHOOL INC.
20A Kangaroo Steet, Raymond Terrace NSW 2324

PO Box 5014, Raymond Terrace East NSW 2324

Phone: 02 49 877009 Email: wlmpres@bigpond.com
ATTENDANCE APPLICATION FORM
Child's Surname *
First Name *
Birth Date *

Day Month Year
Gender *

Female Male
Age
Day/s Interested:

Monday Tuesday Wednesday Thursday Friday
HRS: 8:30am - 4:00pm
Date Pre School is Required

- Day - Month Year
(Note; it may not be possible for your child to commence on this date).
Aboriginal / Torres Strait Island Descent:

YES NO
Low Income Health Care Card Holder:

NO YES
HCC No:
EXP Date

- Month - Day Year
Year your child is to start Kindergarten *

- Month - Day Year

Siblings:

Address *

Contact Numbers:

	Home	Mobile	Work
Phone

Address

Contact Numbers:

	Home	Mobile	Work
Phone

Employer:
Occupation
E-mail
Other Infomation
Has your child been diagnosed with a DISABILITY?

Yes No
(We may be able to apply for funding to assist your child's needs)

(Please attach copies of reports and documentation)
Details of Condition
Have you any Additional Needs? *

Yes No
If Yes comment.
Have any PHYSICAL / MEDICAL or SPEECH concerns?

Yes No
If Yes comment.
Have any BEHAVIOURAL issues?

Yes No
If Yes comment.
ALLERGIES

Yes No
If Yes comment.
EpiPEN Required? *

Yes No
Is your child attending another Centre? *

Yes No
If YES what centre Name?
Should be Empty:

WILLIAMTOWN PRE SCHOOL INC.