Childcare

Waite Campus Childrens Centre

Childcare Expression of Interest

Child's Full Name

Child's Date of Birth *

(actual or expected) Sex: F M Unknown

Proposed booking details *

	Mon	Tue	Wed	Thu	Fri
Arrive:
Depart:

Starting *

For: weeks OR until

Parent/Guardian's Full Name *

Relationship to child *

Daytime phone number *

(1): (2):

Address No./Street *

Town/Suburb *

Postcode:

Email Address

Are you:

(Please tick one or more)
a staff member at Adelaide University and if so, Department name:
a student at Adelaide University and if so, Department name:
studying elsewhere
employed
in a family crisis / child at risk
other

Other Parent/Guardian's Full Name

Relationship to Child

Daytime phone number

(1): (2):

Other Parent/Guardian is

* = details required for this field

I wish to apply for placement as detailed above at the Adelaide Campus Childrens Centre.

I understand that I must complete a Child Care Benefit Application form and submit it to the Family Assistance Office if I intend to claim such benefit. (CCB application forms are available at the Centre and FAO).

I understand that to maintain this place on the waiting list, I / we need to contact the Director of the Centre at least every three months to confirm our continuing interest. Not doing so will mean the deletion of this application from the waiting list.

Please press the Submit button, and the Director of the Centre will respond to you soon.