School Readiness Program – Waitlist Intake Form
Please complete this form to join the waitlist for our School Readiness Program. All information will remain confidential.
Child Details
Please provide details about the child enrolling in the program.
Child's Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Age (in years)
*
Gender
*
Male
Female
Non-binary
Prefer not to say
Other
Primary Language(s) Spoken at Home
*
Kindergarten / Early Learning Centre
*
Planned School (if known)
Proposed School Start Year
Parent / Guardian Details
Please provide details for the primary parent or guardian.
Parent/Guardian Full Name
*
First Name
Last Name
Relationship to Child
*
Please Select
Mother
Father
Grandparent
Guardian
Other
Phone Number
*
Please enter a valid phone number.
Email Address
*
example@example.com
Preferred Contact Method
*
Phone
Email
Areas of Concern
Please select any areas you have concerns about for your child.
Please select the areas of concern for your child (select all that apply):
Attention and listening skills
Following instructions
Early literacy skills (sounds, letters, pre-reading)
Early numeracy skills
Fine motor skills (pencil grip, cutting)
Emotional regulation
Social interaction with peers
Confidence and independence
Separation anxiety
Other (please specify)
Developmental & Support Information
Please provide information about your child's development and any support received.
Has your child received any diagnoses?
*
Yes
No
If yes, please specify the diagnosis/diagnoses:
Is your child currently receiving any allied health supports? (e.g., Speech Pathology, OT, Psychology)
Has your child attended kindergarten or childcare?
*
Yes
No
Are there any behavioural, sensory, or medical considerations we should be aware of?
Previous School Readiness Support
Information about previous participation in school readiness programs.
Has your child previously attended a school readiness program?
*
Yes
No
If yes, please provide details:
Funding Information
Please provide details about any funding that may support your child's participation.
Funding Type
*
NDIS
Private
Medicare
Other
NDIS Plan Type
Self-managed
Plan-managed
NDIA-managed
Plan Manager Name & Email
Availability Preferences
Please indicate your preferred session times.
Preferred Session Times
Weekday mornings
After school
School holiday intensives
Consent
Please read and provide your consent for participation and data collection.
Parent/Guardian Full Name (for consent)
*
First Name
Last Name
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit Application
Submit Application
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