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C4C Playgroups Participation Form

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C4C Playgroups Participation Form

C4C Playgroups Participation Formstudioink2023-06-20T01:16:56+10:00

C4C Playgroups Referral

Anyone can make a referral. Families can self-refer, or professionals can refer families they are working with.

For more information, contact Jenny Prince (Supported Playgroup Coordinator)
Telephone 0447 576 278
Email: playgroup@shinebright.org.au

C4C Playgroups Participation Form

Parent or guardian 1

Parent/guardian 1's name

First Name Last Name

Relationship to child

Phone number

Email

Address

Date of birth

DD slash MM slash YYYY

Date

Country of birth

Identify as Aboriginal and/or Torres Strait Islander?

Aboriginal

Torres Strait Islander

Aboriginal and Torres Strait Islander

Neither

Who lives in the family home?

Aunty, Sister, Grandma etc.

Medical/disability/allergies information:

Is the person a NDIS participant?

Yes

No

Add another parent/guardian?

Yes

Parent or guardian 2

Parent/guardian 2's name

First Name Last Name

Relationship to child

Phone number

Email

Address

Date of birth

DD slash MM slash YYYY

Date

Country of birth

Identify as Aboriginal and/or Torres Strait Islander?

Aboriginal

Torres Strait Islander

Aboriginal and Torres Strait Islander

Neither

Who lives in the family home?

Aunty, Sister, Grandma etc.

Medical/disability/allergies information:

Is the person a NDIS participant?

Yes

No

Name of child(ren) referred to supported playgroup

Child 1

Child 1 name

First Name Last Name

Date of birth

DD slash MM slash YYYY

Date

Sex/gender

Male

Female

Intersex

Other

Country of birth

Do they identify as Aboriginal and/or Torres Strait Islander?

Aboriginal

Torres Strait Islander

Aboriginal and Torres Strait Islander

Neither

Medical/disability/allergies information:

Are they a NDIS participant?

Yes

No

Add another child?

Yes

Child 2

Child 2 name

First Name Last Name

Date of birth

DD slash MM slash YYYY

Date

Sex/gender

Male

Female

Intersex

Other

Country of birth

Do they identify as Aboriginal and/or Torres Strait Islander?

Aboriginal

Torres Strait Islander

Aboriginal and Torres Strait Islander

Neither

Medical/disability/allergies information:

Are they a NDIS participant?

Yes

No

Add another child?

Yes

Child 3

Child 3 name

First Name Last Name

Date of birth

DD slash MM slash YYYY

Date

Sex/gender

Male

Female

Intersex

Other

Country of birth

Do they identify as Aboriginal and/or Torres Strait Islander?

Aboriginal

Torres Strait Islander

Aboriginal and Torres Strait Islander

Neither

Medical/disability/allergies information:

Are they a NDIS participant?

Yes

No

Additional information

Supported playgroup program has been discussed with the family

Yes

No

What does the family believe a supported playgroup could assist with?

Does the family have use of a car?

Yes

No

Will the family be using public transport?

Yes

No

Are there any cultural backgrounds and/or beliefs that we need to be aware of?

Main language spoken at home:

Is an interpreter required?

Yes

No

If yes, what language?

Who can we contact in an emergency?

Emergency contact

First Name Last Name

Relationship to child

Contact phone number

Contact email

Details of agencies currently working with the family. If none, please skip.

Service name

Allocated worker

First Name Last Name

Contact phone number

Email

Add another agency?

Yes

Additional agency 1

Service name

Allocated worker

First Name Last Name

Contact phone number

Email

Add another agency?

Yes

Additional agency 2

Service name

Allocated worker

First Name Last Name

Contact phone number

Email

Add another agency?

Yes

Additional agency 3

Service name

Allocated worker

First Name Last Name

Contact phone number

Email

Who has completed this form?

Name of referrer

First Name Last Name

Relationship to family

Referrer's email address

Referrer's contact phone number

Reason for referral as identified by referrer

ACKNOWLEDGEMENT OF COUNTRY

C4C Bendigo acknowledges the Dja Dja Wurrung and Taungurung peoples as the traditional custodians of the land on which we live, work and play. We pay our respects to leaders and elders past, present and emerging. We express our gratitude in the sharing of this land and our sorrow for the personal, spiritual and cultural costs of that sharing. We commit to working respectfully to honour their ongoing cultural and spiritual connections to this country and hope that we may walk forward together in harmony and in the spirit of healing.

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