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Account Info

Registration Date *

Parents First Name *

Parents Surname *

Username *

User Email *

Password *

CONTACT INFORMATION

Contact Number *

Home Address *

Suburb *

Postcode *

DETAILS OF YOUR CHILD/CHILDREN

All children who attend the center (including those under 6 months of age) must be listed below.

Number of your child/children *

Please only include children who will be attending the playgroup (i.e. 0-5 years old)

Child 1 First Name *

Child 1 Last Name *

Child 1 Date of Birth *

Child 1 Gender *

Male
Female

Child 2 First Name *

Child 2 Last Name *

Child 2 Date of Birth *

Child 2 Gender *

Male
Female

Child 3 First Name *

Child 3 Last Name *

Child 3 Date of Birth *

Child 3 Gender *

Male
Female

Child 4 First Name *

Child 4 Last Name *

Child 4 Date of Birth *

Child 4 Gender *

Male
Female

Child 5 First Name *

Child 5 Last Name *

Child 5 Date of Birth *

Child 5 Gender *

Male
Female

Child 6 First Name *

Child 6 Last Name *

Child 6 Date of Birth *

Child 6 Gender *

Male
Female

Day Attending *

Session *

ADDITIONAL INFORMATION

The following information is required by Playgroup WA to receive Commonwealth funding.

Does your family speak a language other than English?

Does any family member have a disability?

Does your family come from an Aboriginal or Torres Straight Islander background?

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