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Application For Child Care
Northern Rivers Children's Services
Please fill in all the fields below, we may not be able to process your application if there is information missing.
Childcare Application Form
Which care are you applying for?
*
Family Day Care
In Home Child Care
Child Care Centre
Outside School Hours Care
Other
What other care are you applying for?
Your Name
*
Your Name
First
First
Last
Last
Phone Number
*
Mobile Number
Work Phone
Email
*
When is care to start?
*
Parent / Guardian Full Name 1
Parent / Guardian Full Name 2
Home Address
Work / Study Address
Child(ren) Details
Child Name
*
Child Name
First
First
Last
Last
Date of Birth
*
Sex
Female
Male
Is child being immunised?
Yes
No
Please indicate which days that are required for this child
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Monday Start
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11
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30
AM
PM
Monday Finish
12
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11
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00
30
AM
PM
Tuesday Start
12
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10
11
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30
AM
PM
Tuesday Finish
12
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10
11
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30
AM
PM
Wednesday Start
12
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11
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30
AM
PM
Wednesday Finish
12
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30
AM
PM
Thursday Start
12
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11
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30
AM
PM
Thursday Finish
12
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11
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30
AM
PM
Friday Start
12
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10
11
:
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30
AM
PM
Friday Finish
12
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2
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10
11
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30
AM
PM
Saturday Start
12
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2
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5
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9
10
11
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30
AM
PM
Satruday Finish
12
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11
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30
AM
PM
Sunday Start
12
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2
3
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5
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7
8
9
10
11
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30
AM
PM
Sunday Finish
12
1
2
3
4
5
6
7
8
9
10
11
:
00
30
AM
PM
Are the above care days flexible?
Yes
No
Preferred location for care
*
School attending (if applicable)
plus1
Add another child
minus1
Remove child
Reason for care?
Work
Study
Time out
Interaction for child
Other
Other reason for care
Are there any special needs (medical or physical)?
Yes
No
Special needs comments
Serious and/or complex health needs will require a Health Management Plan completed & signed by a Doctor.
Where did you hear about Northern Rivers Children's Services?
*
Website
Facebook
Instagram
TV
Radio
Newspaper
Friends
Flyer
Other (please specify)
Other
Please specify where else you have heard about Northern Rivers Children's Services
If you are human, leave this field blank.
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