Family Day Care online request for child care

If you wish to make a request for care to commence within the next six (6) weeks please complete this online form.

RadDatePicker
RadDatePicker
Open the calendar popup.

Parent/Guardian details

Child/Children details

Child (1) male/female: * (required)

Child (2) male/female:

Child (3) male/female:

Are there any allergies, asthma, illness or disability that we need to be aware of? * (required)

Is your child/children Immunised? * (required)
If no, care is not available.

Are you a permanent resident of Australia? * (required)
If, no you need to update your child’s overseas immunisations on the Australian Immunisation Register (AIR).

Do you have a MyGov account? * (required)

Do you have a Customer Reference Number (CRN) for yourself and your child? * (required)

Have you been assessed by Centrelink for child care subsidy? * (required)

Are pets a concern? * (required)

Care required

Times required eg. 8am to 6pm
Times required eg. 8am to 6pm
Times required eg. 8am to 6pm
Times required eg. 8am to 6pm
Times required eg. 8am to 6pm
Times required eg. 8am to 6pm
Times required eg. 8am to 6pm
Eg. any particular care requirements eg language spoken?

Transport requirements

Does the parent drive? * (required)

Is transport required to/from school or preschool?

(name of school/preschool and session times)
Further information
Type the characters you see in the image below * (Required)

Privacy statement

The personal information requested on this form is required primarily in connection with the provision of Council’s Family Day Care service and to ensure that Council’s records are current and correct. The information will only be shared with those responsible for providing that service or as required or permitted by law. This information may be accessed by contacting Council’s privacy officer on 9524 3333. Council’s privacy policy is available on its website at: http://www.gleneira.vic.gov.au/Privacy