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UNICARE CENTRE and UNICAMPUS KIDS

UNICARE CENTRE	UniCampus Kids	UNICARE (NQ) LIMITED
James Cook University Q 4811	James Cook University Q 4811	ACN 061 144 769
Phone: (07) 4781 5633 Fax: (07) 4781 5733 Email: unicare@jcu.edu.au	Phone: (07) 4781 5934 Fax: (07) 4779 9547 Email: unicampuskids@jcu.edu.au

APPLICATION FOR WAITING LIST

Up-To-Date Immunisation is a Condition of Enrolment at both Centres

CENTRE

Unicare
UniCampus Kids

CHILD'S DETAILS

Surname
First Name
Date of Birth	(DD/MM/YYYY)
or
Expected Date of Birth Or Not Yet Pregnant	(DD/MM/YYYY)

PARENT DETAILS

Parent One/Single Parent

Parent Two

Name

Address

Suburb/City

Postcode

Phone H W

Date of Birth

Email address

Working Full-time	place of employment
Working Part-time	place of employment

Working Full-time	place of employment
Working Part-time	place of employment

Seeking Employment

Studying Full-time

Studying Part-time

Other please specify

Do you require:	1. Full-time Care (5 days/wk)
	2. Part-time Care (specify times)

Please indicate what date you would like attendance from: (DD/MM/YYYY)
An ADMINISTRATION FEE of $20.00 will be charged for any reserved bookings. The $20.00 will be credited to the child care fees when the child commences at Unicare or UniCampus but will be forfeited if the booking is cancelled.

Are there any special requirements for you or your child because of a health problem or disability?

Yes No If yes please specify

Filling out this form ensures your child's name goes onto the waiting list, but this does not guarantee that a vacancy will occur that will allow us to offer a position for your child at Unicare Centre or UniCampus Kids.

Please inform the centre immediately of any changes in your circumstances as this could save any future inconvenience or misunderstanding.