Cockburn Playgroup – New Membership Cockburn Playgroup - New Membership Playgroup Day and Time * Thursday Play & Learn 0-4yrs 9.30am - 11.30am Start Date * Term 1 Term 2 Term 3 Term 4 How many children will accompany you? * Participating Adult #1 (First and Last Name) * Participating Adult #1 Age * Please select from dropdown Under 20 years 20-29 years 30-39 years 40-49 years 50-59 years 60 years and over Participating Adult #1 Gender * Please select from dropdown Female Male Diverse gender Prefer not to say Phone Number * Street Number and Name (home address) * Suburb * Post Code * Email Address * Participating Adult #2 (First and Last Name) Participating Adult #2 Age Please select from dropdown Under 20 years 20-29 years 30-39 years 40-49 years 50-59 years 60 years and over Participating Adult #2 Gender Please select from dropdown Female Male Diverse gender Prefer not to say Child #1 Full Name (First Name and Last Name) * Child #1 Date of Birth * Child #2 Full Name (First Name and Last Name) Child #2 Date of Birth Child #3 Full Name (First Name and Last Name) Child #3 Date of Birth Child #4 Full Name (First Name and Last Name) Child #4 Date of Birth Please advise if you will be accompanied by more than 4 children and include their first and last names and date of birth Do you or your child have any allergies or medical needs? * No Yes Please explain your allergies or medical needs: Do you or your child have any additional needs? * No Yes Please explain any additional needs: Emergency Contact Name * Emergency Contact Phone Number * Do you or your family identify as (select one answer only): * Aboriginal / Torres Strait Islander Born in Australia with English as your first language Born in Australia but English was not your first language Born in a country other than Australia where English was your first language (i.e. Ireland, Scotland, USA, etc.) Born in a country other than Australia where English was not your first language - Culturally and Linguistically Diverse Languages spoken at home * How did you hear about Meerilinga Playgroups? (choose all relevant boxes) * Friend Child Health Nurse Local Library Local School Social media Meerilinga website OtherOther Family Composition (select one answer only) * Single with dependant children Couple with dependant children Extended family OtherOther I give permission for my child/ren to be photographed and understand this may be used on Meerilinga's owned platforms (website, Facebook, centre programs, newsletters) or for advertising purposes. * Yes No I have read and agree to Meerilinga terms and conditions, including cancellation, immunisation and ChildSafe guidelines * Yes See: ChildSafe Guidelines, Immunisation Policy,Terms & Conditions (including cancellation). Would you like to receive information and updates from Meerilinga? * Yes No Fees & Payments. Please note: Playgroup Enrolment is for the current year. Membership fee is $30 per term per family with one child and $35 per term per family with more than one child. Membership fees are due at the commencement of each term. Membership fees for each term can be paid online via PayPal (you will be directed here once you press submit). Alternatively, if you are unable to make a payment this way we will issue you an invoice with our Bank Details to make a Direct Deposit. Payments can be made online with your Credit Card or PayPal account each term via: Online Payment I understand how to pay my Playgroup Membership fees * Yes Meerilinga is funded through the Department for Communities and is required to collect and aggregate data. Individuals information may only be used or disclosed to third parties where permitted by that party or by law. Meerilinga is committed to ensuring that your personal information is kept private. View our Privacy Statement here. If you are human, leave this field blank.