Application Form

MIKARIE CHILD CARE CENTRE
EXPRESSION OF INTEREST FORM

Thank you for your expression of interest in Mikarie Child Care Centre. You will be placed on the wait list (this does not guarantee a placement at the centre).

Please take the time to fill out the below form, ensuring all fields are filled out. Once submitted you should receive a green notification message.
Child's First Name
Child's Middle Name
Child's Last Name
Child's Preferred Name
Child's Gender
Child's Date of Birth
Address
Home Phone
Mobile Phone
Email
Cultural Background
Languages spoken at home
Aboriginal or Torres Strait Islander
Does your child suffer from any allergies?
If yes, please specify
Does your child have any of the following specific health care needs?
Does your child have any additional support needs that we need to be aware of, eg. a disability or delay including intellectual, sensory or physical impairment?
Primary diagnosis
Diagnosis made by
Other details
Preferred start date
How did you hear about us?
Days required (preference 1)
Days required (preference 2)

Parent/ Guardian 1 Details:

First name
Middle name
Last name
Gender
Home phone
Work phone
Mobile
Email
Occupation
Place of work
Type of work
Relationship to child

Parent/ Guardian 2 Details:

First name
Middle name
Last name
Gender
Home phone
Work phone
Mobile
Email
Occupation
Place of work
Type of work
Relationship to child
ACCESSIBILITY OPTIONS
ACCESSIBILITY OPTIONS