Date *

MM

DD

YYYY

CHILDS INFORMATION *

First Name

Last Name

Date of birth *

MM

DD

YYYY

Hours required *

please choose 1 option below

full time (8:30-5:00)

part time (8:30-1:00)

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Does your child have any illness/allergy? *

please choose one

Yes

No

Is your child's immunisations up to date *

Yes

No

Does your child have any health issues which may effect their ability to learn *

Yes

No

Does your child have any physical issues that may effect their ability to learn *

Yes

No

Does your child have any sensory issues such as hearing impairments , visual impairments , language impairments or selective mutism , which may effect their ability to learn *

Yes

No

Does your child have emotional or behavioural issues which may affect their ability to learn *

Yes

No

Is your child currently attending an assessment or awaiting an assessment from an early intervention team, speech &language or child and adolescent mental health service ?

Yes currently attending

awaiting

No

Name *

First Name

Last Name

Phone *

Country

(###)

###

####

Please confirm we are able to use the information provided to contact you.

I agree