Earlybirds Membership Application Form

Membership Application Form
Membership Type

Family Membership - $135 Family Member Concession - $85 (Concession card must be provided upon request) Family Membership - Committee Member - $0 (must be Elected Committee Member)
Preferred Session
(i.e. Monday 11am-1pm)
Parent Name *

First Name Last Name
E-mail
PlaygroupWA Family ID (if known)
Address

Street Address

Street Address Line 2

Suburb State

Post Code
Phone Number

Area Code Phone Number
Country of Birth
(Required info by PlaygroupWA)
Main language spoken at home
(Required info by PlaygroupWA)
Indigenous status
(Required info by PlaygroupWA)
Disability, impairment or allergies?
(Required info by PlaygroupWA)
Do you agree to comply with the Earlybirds Playgroup immunisation policy (refer website)?
(Required info by PlaygroupWA)
Child No. 1 Name
(Required info by PlaygroupWA)
Child No. 1 Date of Birth
(Required info by PlaygroupWA)
Child No. 2 Name
(Required info by PlaygroupWA)
Child No. 2 Date of Birth
(Required info by PlaygroupWA)
Child No. 3 Name
(Required info by PlaygroupWA)
Child No. 3 Date of Birth
(Required info by PlaygroupWA)
Child No. 4 Name
(Required info by PlaygroupWA)
Child No. 4 Date of Birth
(Required info by PlaygroupWA)

My Products

Family Membership $ 135.00 AUD

(Includes PlaygroupWA membership fee of $35)

Family Membership (Concession) $ 85.00 AUD

(Valid Concession Card must be presented upon request)

Family Membership (Committee Memeber) Free

(Must be an appointed committee member for 2021)

Total $ 0.00 AUD

Credit Card

Should be Empty:

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