Early Learning Centre enrolment questionnaire

Student surname*

Student given names*

Date of Birth*

Parent 1 name (Given and Surname)

Parent 2 name (Given and Surname)

Enrolment year?*

Enrolment Year level*

Which term will you begin your enrolment with us?*

If you are wish to start mid-term, please indicate the commencement date

What is your preference for days in 2024?*

Please note this is a preference only based on current offerings. Actual group offerings for 2024 will not be confirmed until place offer stage.

Background Information

Who is in your child's family?*

Who else is important to them? (friends/pets etc)*

Was your child born at full term?*

Yes
No

Were there any birth complications?*

Yes
No

If yes, please provide further details?

Was your child admitted to the special-care nursery?*

Yes
No

If your child already attending a child-care facility, please state the name of this facility.

If yes, please provide further details?

Has your child had their Maternal Child Health checks?*

Yes
No

Were developmental milestones met?*

Yes
No
Some

If no/some please provide further details.

Do you have any concerns with your child's hearing or vision?*

Yes
No

If yes, please provide further details.

Has your child had a hearing test?*

Yes
No

Has your child had a eye test?*

Yes
No

Does your child have any ongoing illness or allergies?*

Yes
No

If yes, please provide further details.

Community

Has your child attended any early learning programs including child care, creche, baby sitting or kindergarten program?*

Yes
No

If yes, how often did your child attend and for what hours?

Do you have any concerns about how your child separates from you?*

Yes
No

If yes, please provide further details.

Wellbeing

Does your child enjoy running, jumping and climbing?*

Yes
No

Do you have any concerns with how your child uses their hands and fingers?*

Yes
No

If yes, please provide further details.

Do you have any concerns with how your child uses their arms and legs?*

Yes
No

If yes, please provide further details.

Is your child left or right handed or still using both?*

Left
Right
Both

Communication

What is your child's first language?*

Does your child speak or understand any other languages?*

Yes
No

If yes, please list the language/s.

Can you easily understand what your child is talking about?*

Yes
No

If no, please give some detail.

Can other people easily understand what your child is talking about?*

Yes
No

If no, please give some detail.

Is your child involved with a speech pathologist?*

Yes
No