Waiting List Application

Centre Manager- Kate Kallista
Phone – 03 9885 6474
Email – samanthas@samanthaschildcare.com.au

Prefer to download a copy? Download PDF wait list application HERE>

Contact Information

Parent 1

Surname*

First Name*

Address*

Email*

Working Status*

Phone (Mobile)*

Phone (Home/Work)*

Preferred Contact Method

Email Phone

Parent 2

Surname

First Name

Address

Working Status

Phone (Mobile)

Phone (Home/Work)

Preferred Contact Method

Email Phone

Child Information

No. of Children:

Child 1 First Name*

Child 1 Surname*

Date of Birth*

Number of days required

Preferred Start Date

Child 2 First Name*

Child 2 Surname*

Date of Birth*

Number of days

Preferred Start Date

Child 3 First Name

Child 3 Surname*

Date of Birth*

Number of days required

Preferred Start Date

Child 4 First Name*

Child 4 Surname*

Date of Birth*

Number of days required

Preferred Start Date

Additional Information

Where did you hear about us?

Does your child have special needs?

Are you an Aboriginal or Torres Straight Islander?

Language spoken at home

Is your Immunisation up to date?

Are there any allergies or anaphylaxis?

Please list allergies

Do you have any siblings at the centre?

Other Comments