Canning Vale Playgroup Inc
PARENT/GUARDIAN DETAILS
Attending parent/guardian surname
*
Attending parent/guardian first name
*
Attending parent/guardian preferred name
Attending parent/guardian postal address
*
Attending parent/guardian contact number(s)
*
Attending parent/guardian email address
*
CHILD DETAILS
Child #1 full name
*
Child #1 gender
*
Please Select
Male
Female
Other
Child #1 date of birth
*
Child #1 allergies/medical conditions
(IF APPLICABLE) Child #2 full name
(IF APPLICABLE) Child #2 gender
Please Select
Male
Female
Other
(IF APPLICABLE) Child #2 date of birth
(IF APPLICABLE) Child #2 allergies/medical conditions
(IF APPLICABLE) Child #3 full name
(IF APPLICABLE) Child #3 gender
Please Select
Male
Female
Other
(IF APPLICABLE) Child #3 date of birth
(IF APPLICABLE) Child #3 allergies/medical conditions
EMERGENCY CONTACT DETAILS (NOT THE PARENT/GUARDIAN WHO WILL BE ATTENDING PLAYGROUP)
Emergency contact name
*
Emergency contact phone
*
Emergency contact relationship to child
*
PREFERRED DAY
Please nominate your PREFERRED day to attend playgroup (we will try and accommodate where possible. All times 9:15AM to 11:15AM
*
Please Select
Monday
Tuesday
Wednesday
Thursday
Friday
What alternate days (if any) are possible to attend? All times 9:15AM to 11:15AM
Monday
Tuesday
Wednesday
Thursday
Friday
HEALTH DETAILS
Are you pregnant and expecting in 2023?
*
Please Select
Yes
No
(IF APPLICABLE) Estimated due date
Do you hold a current healthcare card? (NB: CARD MUST BE SIGHTED BY AN AFFILIATED MEMBER)
*
Please Select
Yes
No
(IF APPLICABLE) If yes, please provide number
(IF APPLICABLE) If yes, please provide expiry
All children attending CVPG must be immunised or provide a Dr's letter as to why they are not. Are immunisations up to date?
*
Please Select
Yes
No
If immunisations are not up to date please provide reason as to why (DOCUMENTARY PROOF MAY BE REQUIRED)
*
I have read the CVPG health guidelines? See website for up to date guideline document
*
Please Select
Yes
No
PLAYGROUP WA DETAILS
Are you currently a member of a playgroup affiliated with Playgroup WA?
*
Please Select
Yes
No
(IF APPLICABLE) If yes, please provide membership number (IF KNOWN)
Would you like to receive info from Playgroup WA with regards to upcoming events? (NB: THIS INFORMATION RELATES TO PLAYGROUP WA NOT CANNING VALE PLAYGROUP)
Email
Mail
Neither
Playgroup WA has requested that we ask all of our members to complete this brief questionnaire for funding purposes.
DOES ANYONE FROM THE ABOVE FAMILY WHO ATTENDS CVPG:
Come from a culturally and linguistically diverse background?
*
Please Select
Yes
No
Come from an Aboriginal or Torres Strait Islander background?
*
Please Select
Yes
No
Have a parent or child with a disability?
*
Please Select
Yes
No
To keep up to date with news and current events, please join our Facebook page: CANNING VALE PLAYGROUP - OFFICIAL PAGE.
Enrolments officer email - enrolmentsCVPG@gmail.com
Bank details for payment
Enrolments officer email - enrolmentsCVPG@gmail.com
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