Early Autism Supports – Expression of Interest Wait list applicationTo be placed on the Community Children's Centre – Early Autism Supports waitlist, please complete the form below and we will contact you as soon as possible. Child details Given name * Family name * Date of birth * Day 12345678910111213141516171819202122232425262728293031 Month JanFebMarAprMayJuneJulyAugSeptOctNovDec Year 19001901190219031904190519061907190819091910191119121913191419151916191719181919192019211922192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024202520262027202820292030203120322033203420352036203720382039204020412042204320442045204620472048204920502051205220532054205520562057205820592060206120622063206420652066206720682069207020712072207320742075207620772078207920802081208220832084208520862087208820892090209120922093209420952096209720982099 What supports are you interested in receiving? * Inclusive Early Years Support – La Trobe Bundoora Campus Inclusive Early Years Support – Community Allied Health and Specialist Support What is the name of the service you currently attend? Please select the type of Allied Health support you are interested in Speech pathology Psychology Assessments Diagnosis of Autism Spectrum Condition? * Not required for enrolment. Yes No Other (eg. Seeking assessment, ASDetect app) If other, please specify What step of the NDIS process are you currently up to? * -- Please Select --We have a current NDIS planWe have had a planning meeting and currently waiting for a planWaiting for access meetingHave not contacted NDIS yet Immunisation **All children attending the centre must be immunised.** To have an enrolment confirmed in our centre, we require a current Australian Immunisation Register (AIR) that shows the child is up to date with all vaccinations that are due for their age, or that they are able to receive according to our current immunisation policy. My child is: * -- Please Select --Fully immunised for their ageUnable to be fully immunised for medical reasons Parent/Guardian details Primary parent/guardian given name * Primary parent/guardian family name * Address * Contact phone number * Email address * Priority access Please note: Priority of Access Guidelines are used to allocate childcare places where more applications are received than the number available. Priority categories Please select one or more of the following categories that best describes your family circumstances: * A child in your family is/has been at risk of serious abuse or neglect Aboriginal and Torres Strait Islander family Families with a person with a disability Single Parent family Receiving Centrelink income/disability support None of the above Validation Privacy Statement All information provided by applicants will be treated as confidential. At La Trobe University, we respect the privacy of your personal information. We collect personal information to follow up on your enquiry. In accordance with privacy laws, personal information about you contained in your enquiry will not be used for any other purpose or disclosed to any person who is not part of the Community Children's Centre, without your permission. You may have the right to access personal information we hold about you, subject to any exceptions in relevant laws, by contacting the Community Children's Centre by emailing our team. The La Trobe University privacy policy can be viewed at: www.latrobe.edu.au/privacy/
