CHILD DETAILS
Surname (required)
First name (required)
Gender (required)
Date of birth (required)
Languages spoken at home (required)
Address (required)
Postcode (required)
DIAGNOSIS
Diagnosis
Date of diagnosis
Paediatrician
Diagnostic Report Acceptable formats: pdf, doc, docx, jpeg, jpg, png Max Size: 5mb
NDIS Funding YesNoPending
NDIS Management Self-managedPlan ManagedAgency Managed (we are not a register service)
NDIS No.
NDIS Start Date
NDIS End Date
PARENT / GUARDIAN 1
Address or as above (required)
Email (required)
Phone (required)
PARENT / GUARDIAN 2
Surname
First name
Address or as above
Email
Phone
SERVICES
Preferred Services (required) Early Intervention TherapyFeeding TherapyHome VisitsMainstream Preschool VisitsOccupational TherapyPsychologySchool Readiness GroupSpeech Therapy
Additional Comments
ADDITIONAL INFORMATION
Child Care Centre Name
Child Care Centre Address
Child Care Centre Phone
Child Care Centre Contact Person
Days attending Child Care Centre MondayTuesdayWednesdayThursdayFriday
Other services / therapists
PRIORITY OF ACCESS - The answers you give here will determine your priority of access
Is this child currently declared 'at risk' of serious abuse or neglect by Department of Communities and Justice, Police, other agencies or this service? YesNo
If Yes, please give details
Please list any siblings currently enrolled at a Kids' Uni Service Sibling 1 Name
Sibling 1 date of birth
Sibling 1 Kids' Uni Centre —Please choose an option—Kids' Uni NorthKids' Uni SouthKids' Uni Innovation CampusKids' Uni Early Intervention
Sibling 2 Name
Sibling 2 date of birth
Sibling 2 Kids' Uni Centre —Please choose an option—Kids' Uni NorthKids' Uni SouthKids' Uni Innovation CampusKids' Uni Early Intervention
Are you a current student of UOW? YesNo
If yes, please list student number Please note proof of enrolment will be required on offer of placement
Are you a current staff member of UOW or UOW Pulse? YesNo
If yes, please list your faculty or department
I understand and agree to notify Kids' Uni should my circumstances change in order to keep all information up to date
Relationship to child (required)
