WAIT LIST FORM — Riverside Preschool

APPLICATION FOR WAIT LIST

Child's Given Name:

First Name

Last Name

M/F:

Male

Female

D.O.B. Please note American format:

MM

DD

YYYY

Home Tel:

Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Care Giver:

1: Care Giver's Name:

First Name

Last Name

Email:

Mobile:

2: Care Giver's Name:

First Name

Last Name

Email:

Mobile:

Language spoken in the home:

Do you have a Low income Health Care Card

YES

NO

Additional needs:

Is your child of Aboriginal or Torres Strait Island decent?

Yes

No

Have you had a child previously enrolled at Riverside:

YES

NO

How did you hear about Riverside?

Please pay the $50 waitlist fee, through the PayPal button on the Website.