Application form – BIRREGURRA PRESCHOOL CENTRE

Enrolment information

You can save your form at any time and return to complete it when you're ready. Just scroll down to the bottom of the page and click on save. Please complete a separate form for each child you are enrolling.

Is your child fully immunised for their age?*

Yes
No

This application is for my child to attend the:*

Three-year-old kindergarten program
Four-year-old kindergarten program

This application is for my child to attend the three-year-old program in the year:*

This application is for my child to attend the four-year-old program in the year:*

Is this application for a second year funded program?*

Yes
No

Please attach relevant paperwork.*

DEECD notification letter of approval for second year of kindergarten.

Names of other children who have already attended Birregurra Pre School (if applicable)

Family Details

Child's family name*

Given names*

Date of birth*

Proof of Date of Birth*

Please upload a photo of your child's birth certificate or other proof of birth document.

Child's gender*

Name of primary parent/guardian contact*

Address*

Street Address Address Line 2 Town Postcode

Is this your postal address?*

Yes
No

Postal address

Address Line 1 Address Line 2 Town Postcode

Phone number*

Put the best number for us to contact you on here.

Home phone

If you would like to also list a home phone or additional contact number, please place it here.

Email*

Would you like to add a second parent/guardian contact?*

Additional parent/guardian contact

Additional contact address

If you would like to add a second residential address, please list it here.

Street Address Address Line 2 Town Postcode

Is this your additional parent/guardian's postal address?*

Yes
No

Postal address

Address Line 1 Address Line 2 Town Postcode

Additional parent/guardian contact phone number

Put the best number for us to contact you on here.

Additional parent/guardian email

If you would like to list a second email address, please put it here.

Concession Entitlements

Subsidy entitlement

DEECD provides a fee subsidy for Health Care Card holders (funded kindergarten program only). Please indicate (tick) if you or your child holds one of the below concessions. If you have more than one, please select only one of the concessions you are entitled to.

Commonwealth Health Care Card
Commonwealth Pensioner Concession Card
Card/Visa 786/785

Concession card number and expiry date*

Additional information

Does your child have additional needs?*

Yes
No

Please specify your child's additional needs.*

You are encouraged to discuss your child's needs with the teacher when your child's place is confirmed.

Is your child registered with a specific agency?*

Yes
No

Name of agency*

Is your child of Aboriginal or Torres Strait Islander descent?*

Submit your application

Parent/guardian name*

First Last

Relationship to the child enrolling in Birregurra Pre School*

Consent*

I agree that all the information I have provided in this form is true and correct.

I agree