Phone: (08) 8553 2436 Fax: (08) 8553 2483

Enrolment Form

Parents Name (required):

DOB:

Contact Details:
Home Phone (required):

Mobile:

Email (required):

Postal:

Residential:

Are you of Aboriginal &/or Torres Strait Islander descent?

What is your country of birth?

What language is spoken at home?

Do you have a disability (intellectual/learning/psychiatric/speech etc)?

What is your main source of income? (please circle most appropriate answer)

Do you give permission for parenting KI to contact you to obtain follow-up information data?

Child’s Detail:
Name:

DOB:

Other information(special needs, country of birth,etc):

I consent to myself or my child to be photographed and for their image and name to be used in circumstances the Parenting KI Project Officer deems to be appropriate. This could include for publication, in group photos to families, advertising and promotional material.
Signed:

I give permission for the above information & attendance at Parenting KI activities to be entered into the Department of Social Services DEX reporting system.
Signed:

Additional Comments: