NEW PlayConnect+ Family Registration Form

PlayConnect+ Playgroups are funded by Autism Queensland and each family attending is required to register with the program by completing a registration form which is returned to Playgroup NSW. Please note that this information is recorded securely within the DEX portal with information kept private and confidential.

All registered members will receive free membership with Playgroup NSW.

Select the playgroup you attend?*

join date

Date

Active

Parent/Carer's Name*

First NameLast Name

Which most accurately describes you?*

Carer type*

D.O.B*

Date

Mobile*

Relationship to the child/ren*

Email*

example@example.com

Address*

Street Address

Suburb

Postcode

Are you of Aboriginal or Torres Strait Islander descent?*

Do you identify as culturally or linguistically diverse?*

Do you identify as having a disability?*

Do you identify as having any of the following disabilities?*

Please specify *

Are you eligible for NDIS?*

If eligible for NDIS, do you have a NDIS plan?*

What is your country of birth?*

What language is spoken in the home?*

Please specify other language *

What is your highest level of education/qualification?

What is your household composition?

Are you a carer?

What is your employment status?

Are you currently experiencing homelessness?

Where did you hear about this playgroup?

How many children will be attending with you?*

1234

Registration type (child 1)*

Child's Name (1)*

First NameLast Name

Gender*

D.O.B*

What is this child's country of birth?*

Does the child identify as culturally or linguistically diverse?*

Does this child have an Aboriginal or Torres Strait Islander background?*

Are there concerns about this child’s development *

Please specify *

Does this child have any of the following disabilities?*

Please specify*

Is the child eligible for NDIS?*

If eligible for NDIS, does the child have a NDIS plan?*

Registration type (child 2)*

Child's Name (2)*

First NameLast Name

Gender*

D.O.B*

Date

What is this child's country of birth?*

Does this child have an Aboriginal or Torres Strait Islander background?*

Does the child identify as culturally or linguistically diverse?

Are there concerns about this child’s development *

Please specify *

Does this child have any of the following disabilities?*

Please specify *

Is the child eligible for NDIS?*

If eligible for NDIS, does the child have a NDIS plan?*

Registration type (child 3)*

Child's Name (3)*

First NameLast Name

Gender*

D.O.B*

Date

What is this child's country of birth?*

Does this child have an Aboriginal or Torres Strait Islander background?*

Does the child identify as culturally or linguistically diverse?

Are there concerns about this child’s development *

Please specify *

Does this child have any of the following disabilities?*

Please specify *

Is the child eligible for NDIS?*

If eligible for NDIS, does the child have a NDIS plan?*

Registration type (child 4)*

Child's Name (4)*

First NameLast Name

Gender*

D.O.B*

Date

What is this child's country of birth?*

Does this child have an Aboriginal or Torres Strait Islander background?*

Does the child identify as culturally or linguistically diverse?

Are there concerns about this child’s development *

Please specify *

Does this child have any of the following disabilities?*

Please specify *

Is the child eligible for NDIS?*

If eligible for NDIS, does the child have a NDIS plan?*

Consent Policy

All families participating in the PlayConnect + Program run through Playgroup NSW are required to complete a Registration Form with personal information about themselves and their children. Your personal information is protected by law, including the Commonwealth Privacy Act.

As part of the funding contract the personal information that is collected from you is required to be entered into an IT system called the ‘DATA EXCHANGE’ which 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 for the purposes of providing a service to your family.

DSS de-identifies your data, which means they remove information that identifies you and/or your child. DSS combines your data with other clients data to identify trends at the program level and use the information to develop policy, conduct research and evaluations.

DSS may use this data to produce reports and these reports maybe shared with other organisations. You can find more information about how DSS will manage your personal information in the DSS Privacy Policy on their website: http://www.dss.gov.au/privacy-policy

PlayConnect+ staff will be requesting that you sign consent at the first Playgroup you attend.

You do not have to consent to sharing your personal information with DSS and this will not affect the service you receive. If you do not consent you can ask for your information to be removed at anytime.

Questions and Further Enquiries

For more information please email Playgroup NSW at admin@playgroupnsw.org.au

I acknowledge that I have read (or have had explained) and understand the information outlined above*

I consent to the information being entered onto the databases explained in this form.*

Signature*

Would you like to receive our eNewsletter?*

YesNo

PlayConnect+ Family Registrations