If you require help completing this form, please reach out to Hills Community Aid 96398620, and a representative will be in touch with you.

Please choose which program you are registering for

Which Playgroup would you like to attend? *

Session 1 - Tuesday, 9.15am - 10.45am Session 2 - Wednesday, 9.15am - 10.45amSession 3 - Wednesday, 11am - 12.30pm

Parent / Carer First Name *

Parent / Carer Last Name *

Address *

Suburb *

Postcode *

Contact Phone Number *

Email Address *

Gender *

Date of Birth *

Country of Birth *

Main Language Spoken at Home *

Do you identify as Aboriginal? *

YesNo

Do you identify as Torres Strait Islander? *

YesNo

Other

In case of an emergency who should we contact?

Name of Contact *

Relationship to you *

Phone Number *

How many children are you registering? *

Child 1 First Name *

Child 1 Last Name *

Child 1 Date of Birth *

Child 1 Country of Birth *

Child 1 Gender *

Other

Child 2 First Name *

Child 2 Last Name *

Child 2 Date of Birth *

Child 2 Country of Birth *

Child 2 Gender *

Other

Child 3 First Name *

Child 3 Last Name *

Child 3 Date of Birth *

Child 3 Country of Birth *

Child 3 Gender *

Other

Child 4 First Name *

Child 4 Last Name *

Child 4 Date of Birth *

Child 4 Country of Birth *

Child 4 Gender *

Other

Do you consent for Hills Community Aid to take and use photographs for promotional purposes ?

YesNo

Would you like to be kept up to date about Hills Community Aid information via email? *

YesNo

Other

CONSENT
The information you provide on this form includes your personal information. Your personal information is protected by law, including by the Commonwealth Privacy Act. We are using an IT system called the ‘Data Exchange’ to store your information. This system is hosted by the Australian Government Department of Social Services (DSS). The personal information that is stored on the Data Exchange is only disclosed to us to manage your case.
You do not have to consent to sharing your personal information with DSS. If you do not consent to us sharing your personal information, it will not affect the services you receive. If you do consent to sharing your personal information with DSS, you can ask for this information to be removed at any time. DSS de-identifies your data. This means they remove information that identifies you or that could be used to re-identify you (e.g. your name).
DSS combine your data with other clients’ data in the Data Exchange to identify trends at the program level. This information is used to develop policy, administer grants programs, and conduct research and evaluations. DSS may use this data to produce reports. These reports may be shared with other organisations. The data in these reports is de-identified.
You can find more information about how DSS will manage your personal information in the DSS privacy policy on their website.

Do you consent to collect this information for reporting purposes to the Department of Social Services Data Exchange (DS)? *

YesNo

Do you consent to future contact from Department of Social Services Data Exchange(DS) for survey / research / evaluations? *

YesNo

Terms and Conditions

I acknowledge that it is my responsibility to participate in activities within my own limits and capabilities, to prevent any injury.
I expressly waive any claims I may have against Hills Community Aid for any injury or loss sustained by me while undertaking any classes.
I understand that I am responsible for my child/rens actions.

I acknowledge that I have read and understood the above statements. *

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Date: *