Bullsbrook Playgroup – New Membership Bullsbrook Playgroup - New Membership Playgroup Day and Time * Play and Connect, Thursday 11am-2pm Start Date * Term 1 Term 2 Term 3 Term 4 I am a resident of the City of Swan and have a health care card If you are a resident of the City of Swan and have a health care card, please contact Mihi.Betham@meerilinga.org.au as financial assistance may be available. More details can be found here: Access-All-Areas-Information-Sheet How many children will accompany you? * Participating Adult #1 (First and Last Name) * Participating Adult #1 Age * Please select from dropdownUnder 20 years20-29 years30-39 years40-49 years50-59 years60 years and over Participating Adult #1 Gender * Please select from dropdownFemaleMaleDiverse genderPrefer 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 dropdownUnder 20 years20-29 years30-39 years40-49 years50-59 years60 years and over Participating Adult #2 Gender Please select from dropdownFemaleMaleDiverse genderPrefer 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 If you are human, leave this field blank.