All sections of the application form must be completed. Where information is not applicable please enter N/A. Where information is unknown please enter UNKNOWN. Please read consent and privacy information provided on pages 7 and 8 and sign consent where indicated. Child Details Child’s First Name Child’s Surname Date of Birth Gender Male Female Home Address Is the of: Aboriginal origin Torres Strait Islander origin Both Aboriginal & Torres Strait Islander origin Neither Does the child: Live with others, provide details below Live with parents Country of birth Is the an Australian citizen? Yes No If the child is not an Australian citizen do they hold: 1. A permanent visa or are they a protected Special Category Visa holder? Yes No 2. type of visa, please specify (e.g. Bridging Visa, Temporary Protection Visa, Protection Visa Does the parent or qualify for, and receive any of the following payments / benefits? Carers allowance Yes No Applied for Family Health Care Card Yes No Parent/Carer Details Adult 1: Name Relationship to child (e.g. mother, father, grandfather) Home address Is this adult: Aboriginal origin Torres Strait Islander origin Both Aboriginal & Torres Strait Islander origin Neither Contact Phone Number(s) Email Preferred language Preferred contact Phone Letter Email Adult 2: Name Relationship to child (e.g. mother, father, grandfather) Home address Is this adult: Aboriginal origin Torres Strait Islander origin Both Aboriginal & Torres Strait Islander origin Neither Contact Phone Number(s) Email Preferred language Preferred contact Phone Letter Email
All sections of the application form must be completed. Where information is not applicable please enter N/A. Where information is unknown please enter UNKNOWN. Please read consent and privacy information provided on pages 7 and 8 and sign consent where indicated. Child Details Child’s First Name Child’s Surname Date of Birth Gender Male Female Home Address Is the of: Aboriginal origin Torres Strait Islander origin Both Aboriginal & Torres Strait Islander origin Neither Does the child: Live with others, provide details below Live with parents Country of birth Is the an Australian citizen? Yes No If the child is not an Australian citizen do they hold: 1. A permanent visa or are they a protected Special Category Visa holder? Yes No 2. type of visa, please specify (e.g. Bridging Visa, Temporary Protection Visa, Protection Visa Does the parent or qualify for, and receive any of the following payments / benefits? Carers allowance Yes No Applied for Family Health Care Card Yes No Parent/Carer Details Adult 1: Name Relationship to child (e.g. mother, father, grandfather) Home address Is this adult: Aboriginal origin Torres Strait Islander origin Both Aboriginal & Torres Strait Islander origin Neither Contact Phone Number(s) Email Preferred language Preferred contact Phone Letter Email Adult 2: Name Relationship to child (e.g. mother, father, grandfather) Home address Is this adult: Aboriginal origin Torres Strait Islander origin Both Aboriginal & Torres Strait Islander origin Neither Contact Phone Number(s) Email Preferred language Preferred contact Phone Letter Email