Hibiscus Children’s Centre Waiting List Form

Hibiscus is a non profit Community child care Centre, open 46 weeks per year. Hours are 8.30-4.30.
Hibiscus cares for children ages 3-5 years. Parents are welcome, encouraged and relied upon to become
involved in the Hibiscus Community.

Child’s Full Name:_______________________________Date 0f Birth_____/_____/_____

Address: ________________________________________________________________

Parent/ Guardian Name: ____________________________________________________

Relationship to the child: ____________________________________________________

Home Phone : __________________________ Mobile: ___________________________

Email : __________________________________________________________________

Proposed Booking Details, please circle days requested.

Monday Tuesday Wednesday Thursday Friday

Year in which child will be eligible to attend school (child must be 5 years old on
July 31st):
___________________________________________________________________

Access Guidelines
We abide by the priority of access guidelines set down by the Department of Family and
Community Services. To help us equitably fill vacant places, please circle .

* Child with Additional Needs ( Referral & Documentation needed). YES / NO

* Child attached to an Agency e.g Life Start, Family Services etc. YES / NO
* Child from non english speaking background YES / NO
* Parent studying or seeking employment YES / NO
* Single parent YES / NO
* Do you have a Aus Government Health Care Card YES / NO
* Do you or your child Identify as Aboriginal or Torres Strait Islander YES / NO
* Will you child be enrolling in Daceyville Public School once school age YES / NO
______________________________________________________________________
______________________________________________________________________
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Note : Completion of this form does not guarantee a position for your child nor the pattern
of attendance requested - Thanks
Parent/ Guardian Signature : ________________________________________________
Date: ___________________________________________________________________

OFFICE USE : Date Received: