Waitlist for an ECMS service

First name*

Last name*

Email*

Mobile phone number*

Street address*

Suburb*
Postcode*

State*

Local Government Area (LGA)*— Please Select —BanyuleBoroondaraBrimbankCardiniaCaseyDarebinHobsons BayKingstonManninghamMaribyrnongMelbourneMeltonMooraboolNillumbikWhittleseaWyndham

Please select the ECMS service you would like to enrol at*— Please Select —Altona Early Years HubBulldogs Community Children's CentreChurch Street Children's CentreHurstbridge Children's CentreMaribyrnong River Children's CentreMossfiel Children's CentreNewport Gardens Early Years CentreOakhill Family Centre

Your child’s name*

Your child’s date of birth*

When would you like your child to start?*

What days would you like long day care for?*MondayTuesdayWednesdayThursdayFriday

The following questions help us identify whether you are eligible for priority of access, in accordance with the Priority of Access Guidelines set out in the Child Care Benefit (Eligibility of Child Care Services for Approval and Continued Approval) Determination 2000.

Is your child a triplet or quadruplet?YesNo

Is your child from Refugee or Asylum Seeker background?YesNo

Is your child currently in an Out of Home Care arrangement including kinship care?YesNo

Have you or your family had contact with Orange Door or Child Protection?YesNo

If your child is accessing one of the following services, please let us know.— Please Select —Early Childhood InterventionCommunity HealthPrivate TherapistNDISOther

Is your child in a family which includes a person with a diagnosed disability?YesNo

Are you working or studying? Please select the option below that best describes you— Please Select —I am a single parent who is working or studyingBoth parents in the home are working or studying

My child is Aboriginal or Torres Strait Islander*YesNo

Which of the following Concession cards do you have?Commonwealth Health Care CardCommonwealth Pensioner Concession CardDepartment of Veterans' Affairs Gold Card or White CardIn-country Special Humanitarian visa (subclass 201)Global Special Humanitarian visa (subclass 201)Temporary Humanitarian Concern visa (subclass 201)Refugee visaProtection visa (subclass 866)Emergency Rescue visa (subclass 203)Woman at risk visa (subclass 204)Bridging visas A-E

Additional informationI already have a child at this serviceI'd like to speak with you about enrolling more than one child.
Is there anything else you think we should know at this point?

I understand that ECMS regards my information as confidential and has policies in place to ensure the protection of this information.
I understand that this data may be used for statistical purposes.
I am the legal Guardian of the Child and have authority to provide the information contained in this form.
By completing this waiting list application it does not guarantee nor confirm placement for my child at my selected service.