Supported Playgroup: Member Registration Form

Contact Information

Supported Playgroup Registration Form

Our supported playgroups funding obligations require each family attending our programs to complete a registration form. Completed forms must be submitted to Playgroup NSW. Please note that all information provided is recorded securely and kept private and confidential.

All registered members will receive free membership with Playgroup NSW.

Playgroup Details

Secret Field

Program Type

Do Not Delete or update visibility. This field controls the lookup

Program *

Select Playgroup *

How did you hear about us? *

How Did You Hear About Us (Other) *Please specify how you heard about us if your answer is not listed in the options above.

Please Note: PlayConnect+ Playgroups are funded by Autism Queensland. Please note that information provided in this registration form is recorded securely within the DEX portal with information kept private and confidential.

Please Note: Play Strong Playgroups are funded by the Department of Education. The following information will assist in the planning and provision of culturally appropriate and inclusive playgroup services.

Please Note: PALS Playgroups are funded by DSS. Please note that this information is recorded securely with information kept private and confidential.

Please Note: Play2Thrive Playgroups are funded by DSS. Please note that information provided in this registration form is recorded securely within the DEX portal with information kept private and confidential.

Your Contact Details

First Name *

Last Name *

Date of Birth *

Gender *

Email *

Mobile *

Address *

Street Address *

Suburb *

State *

Postcode *

Background Information

Your Highest Level of Education/ Qualification?

Your Employment Status

Are you Experiencing Homelessness?

Main Language Spoken at Home *

Main Language (if selected other) *

What is your Household Composition?

Are you a Carer?

Aboriginal or Torres Strait Islander Background *

Please share any additional information about your child(ren) or family that may help us better support you. *

Other Disabilities *

Details of Children

Child 1 Details

Child First Name *

Child Last Name *

How is this child related to you? *

Birthdate *

Gender *

Does this child attend formal Childcare? *

Aboriginal or Torres Strait Islander Status *Please select the option that best describes the child’s identity.

Child's Country of Birth *

Country of Birth (Other) *

Does this child have any Allergies? *

YesNo

If yes, please list all known allergies your child has. *

Other Disabilities *

Is the child eligible for NDIS? *

If eligible for NDIS, do you have a NDIS Plan? *

Child 2 Details

Child First Name *

Child Last Name *

How is this child related to you? *

Birthdate *

Gender *

Does this child attend formal Childcare? *

Aboriginal or Torres Strait Islander Status *Please select the option that best describes the child’s identity.

Child's Country of Birth *

Country of Birth (Other) *

Does this child have any Allergies? *

YesNo

If yes, please list all known allergies your child has. *

Other Disabilities *

Is the child eligible for NDIS? *

If eligible for NDIS, do you have a NDIS Plan? *

Child 3 Details

Child First Name *

Child Last Name *

How is this child related to you? *

Birthdate *

Gender *

Does this child attend formal Childcare? *

Aboriginal or Torres Strait Islander Status *Please select the option that best describes the child’s identity.

Child's Country of Birth *

Country of Birth (Other) *

Does this child have any Allergies? *

YesNo

If yes, please list all known allergies your child has. *

Other Disabilities *

Is the child eligible for NDIS? *

If eligible for NDIS, do you have a NDIS Plan? *

Child 4 Details

Child First Name *

Child Last Name *

How is this child related to you? *

Birthdate *

Gender *

Does this child attend formal Childcare? *

Aboriginal or Torres Strait Islander Status *Please select the option that best describes the child’s identity.

Child's Country of Birth *

Country of Birth (Other) *

Does this child have any Allergies? *

YesNo

If yes, please list all known allergies your child has. *

Other Disabilities *

Is the child eligible for NDIS? *

If eligible for NDIS, do you have a NDIS Plan? *

Child 5 Details

Child First Name *

Child Last Name *

How is this child related to you? *

Birthdate *

Gender *

Does this child attend formal Childcare? *

Aboriginal or Torres Strait Islander Status *Please select the option that best describes the child’s identity.

Child's Country of Birth *

Country of Birth (Other) *

Does this child have any Allergies? *

YesNo

If yes, please list all known allergies your child has. *

Other Disabilities *

Is the child eligible for NDIS? *

If eligible for NDIS, do you have a NDIS Plan? *

Form Submission

Additional Adults

Will any Additional adults be attending the playgroup with you or the children listed in this form? *

YesNo

Please provide the details of additional adults attending

Emergency Contact Details

Emergency Contact First Name *

Emergency Contact Last Name *

Relationship with you *

Mobile *

Consent

I Agree to the Terms & Conditions. *

I have read and acknowledge the Privacy Policy. *

Would you like to receive our eNewsletter?* *

YesNo

As part of the funding contract the personal information that is collected from you is required to be entered into an IT system called the ‘DATA EXCHANGE’ which is hosted by the Australian Government Department of Social Services (DSS). The personal information that is stored on the Data Exchange is only disclosed to us for the purposes of providing a service to your family.

DSS de-identifies your data, which means they remove information that identifies you and/or your child. DSS combines your data with other clients data to identify trends at the program level and use the information to develop policy, conduct research and evaluations.

DSS may use this data to produce reports and these reports maybe shared with other organisations. You can find more information about how DSS will manage your personal information in the DSS Privacy Policy on their website: http://www.dss.gov.au/privacy-policy

You do not have to consent to sharing your personal information with DSS and this will not affect the service you receive. If you do not consent you can ask for your information to be removed at anytime.

I AgreeI Do Not Agree

Source

Form Category

RecordType

Link to Form