Application for access to early childhood development programs and services (updated July 2015)

Application for access to early childhood development programs and services (updated July 2015)
Application for Access to Early Childhood
Development Programs and Services
Updated July 2015
Early childhood development programs and services provide support to children with diagnosed
or suspected disability prior to their enrolment in Prep. The aim of this support is to develop
skills and behaviours to maximise their participation in schooling.
Early childhood development programs and services include centre-based, outreach and
specialist teacher/advisory visiting teacher services to children prior to their enrolment in Prep.
It is important to note that whilst the Department provides early childhood development
programs and services to support children prior to Prep, this is not considered enrolment at a
state school. Prep is the first year of schooling and any services provided by the Department
prior to this are considered a registration only.
This application is completed in collaboration with the child’s parent/carer, and relevant
members of the education team, and submitted to regional office for approval of the child’s
registration in an early childhood development program and/or service.
This application is used to record:

parent/carer consent for departmental officers to collect information to assist in determining
the child’s eligibility for and participation in early childhood development programs and
services.

information collected to determine the child’s eligibility for and participation in early childhood
development programs and services.
Privacy Statement
The Department of Education and Training (DET) is collecting personal information on this form about your child’s
medical, developmental and educational status and history for the purpose of determining your child’s eligibility to
register for access to early childhood development programs and services run by DET and to record your consent
for necessary activities. The information will be kept in a secure location and will only be accessed by relevant
departmental personnel for the purposes outlined above. The child’s information will not be given to any other
person or external body unless consent has been provided or DET is permitted or required by law to do so. If you
have a concern or complaint about the way your personal information has been collected, used, stored or
disclosed, please contact the Principal Education Officer, Student Services in your regional office in the first
instance.
Parent/Carer Consent
Child’s Name
DOB
Age
Proposed Centre or
Program
Application
Type
initial
review
Parent/Carer Consent and Acknowledgement
I understand that:

I can withdraw consent for this application to proceed at any time before a decision is made;
and

if the application is approved, information about my child’s disability and early childhood
development program and service will be recorded on the departmental record management
system for the purpose only of informing the provision of an appropriate early childhood
development program or service; and

I will be expected to participate in any review processes as appropriate or at my request.
Initial and
date here
In considering this application, I give consent for:
The department to collect personal information for the purpose of determining
eligibility for and provision of early childhood development programs and services.
The sharing of any information between the early childhood development program
or service with departmental guidance officers, advisory and specialist teachers,
therapists and State Schools Registered Nurses in order to inform the provision of
an appropriate early childhood development program or service.
The sharing of diagnostic information, information to inform educational planning
and support provision between the early childhood development program and/or
service and the Current Services Supporting My Child listed below.
Please note, services listed may have their own parent consent requirements that must be met
before information they have can be shared with DET e.g. Early Childhood Education and Care
Services.
When my child is transitioning and subsequently enrolled in a state or non-state
school: Sharing of all information regarding my child’s early childhood development
program and service with relevant school and education personnel for the purpose
of informing his/her educational planning and program at their future state or nonstate school.
Parent/Carer Name:
Date:
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Parent/Carer Signature:
Child’s Details
Last Name:
First Name:
Date of Birth:
Male
Female
Home Address:
Child Residency Status:
Australian Citizen
Permanent Visa Holder
New Zealand Citizen
Pacific Island Nation not requiring
visa
Temporary Visa Holder*
Contact EQI prior to registering to confirm fee paying
criteria
Is the student of Aboriginal or Torres Strait Islander origin?
No
Aboriginal
Torres Strait Islander
Both Aboriginal and Torres Strait Islander
Medical conditions: (including allergies/sensitivities):
Court orders:
Are there current Family Court or other court orders concerning the welfare, safety or parenting
arrangements of your child/children?
Yes
No
Please provide a copy of any relevant current court order.
Parent/Carer Name:
Mr
Mrs
Ms
Parent/Carer Name:
Miss
Dr
Mr
Mrs
Ms
Miss
Dr
Relationship to student:
Relationship to student:
Contact Phone Number 1:
Contact Phone Number 2:
Contact Phone Number 1:
Contact Phone Number 2:
Email address:
Email address:
Residential Address (if different to above):
Residential Address (if different to above):
Mailing Address: (if same as residential,
write ‘as above’)
Mailing Address: (if same as residential, write ‘as
above’)
Emergency Contact:
Emergency Contact:
Name:
Name:
Phone Number:
Phone Number:
Additional emergency contact information:
Additional emergency contact information:
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Current Services Supporting My Child (including current educational programs e.g.
kindergarten)
Organisation/Agency Programs/Services Contact Person
Contact Details
Provided
Eligibility Information (e.g. Head of Special Education Services (HOSES)/Advisory Visiting
Teachers (AVT)/Specialist teacher to collect information in consultation with the parent/carer and
other team members as relevant)
Outline child’s significant education support needs:

Learning

Communication

Access to learning/learning environment (e.g. mobility and fine motor)

Socio-emotional

Health and safety
Information from approved specialist providing evidence of diagnosis or suspected diagnosis:
Attach reports (list below)
ASD
HI
ID
PI
SLI
VI
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Early Childhood Development Program and Service Requirements (HOSES/AVT/Specialist
teacher to develop in consultation with family and other team members as relevant)
Outline the aims, focus and strategies:
Recommended Service Provision (HOSES/AVT/Specialist teacher to develop in consultation
with parent/carer and other team members as relevant)
Outline recommended service provision e.g. centre-based sessions, outreach or professional
development provision to other education programs (kindegarten or child care), outreach to home:
Consider the best way to achieve the outlined aims, focus and strategy across learning
environments.
The information provided reflects the information available to the team at the time of
submitting this request.
(HOSES/AVT/Specialist teacher/Guidance
Parent/Carer
Officer)
Name:
Name:
Signed
Signed
Date:
Date:
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Principal Education Officer, Student Services Decision-Making
There are documented significant education support needs:
Yes
No
There is evidence from approved specialist indicating a diagnosis or suspected diagnosis of:
ASD
ID
SLI
HI
VI
PI
no diagnosis/suspected diagnosis provided at this
time
The recommended service provision is appropriate for program requirements:
Yes
No
Reviews
Review required of Educational Support Needs:
Date required:
Review required of suspected diagnosis:
Date required:
Review of program and goals (centre/service based review):
I
recommend/
do not recommend access to the listed early childhood development
program and/or service with the requirements for a review listed above.
Name:
Signed:
Date:
Principal Education Officer, Student Services
Reasons if program/service access is not recommended
I approve/ do not approve access to the listed early childhood development program
and/or service with the requirements for a review listed above.
Name:
Signed:
Date:
Principal Advisor, Education Services (or equivalent)
In the event of the application being unsuccessful, please provide the following details in
relation to the decision making process:
The decision was made for the following reasons:



In arriving at this decision, the following were considered:



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Finalising the process:
In the event of a successful application:
Copy stored on TRIM.
Original form returned to early childhood development program to be filed in child’s file.
OneSchool registration completed for the child outlining early childhood development
program and/or service details nominated on the application form.
Application form uploaded onto OneSchool in Record of Contacts.
Copies of signed form sent to parent/carer(s) notifying them of the successful application and
that their child can now access the nominated early childhood development program and/or
service.
In the event of an unsuccessful application:
If the parent/carer is able to provide further information to support an application the
parent/carer may submit a further application.
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