Foundations for Learning Form

Agency Name:

Referrer's Name and Position:

Physical /Postal Address:

Telephone:

Mobile:

Fax or Email:

Consent from Family for Referral:

Date of Referral:

Child's Full Name:

Date of Birth (Child must be 3-4 years old):

Ethnicity:

Gender:

Full Name & Relationship to Child:

Full Physical Adress:

Phone:

Mobile:

Date of Birth:

Ethnicity:

Full Name & relationship to Child:

Address (full):

Phone:

Mobile:

Age:

Date of Birth:

Ethnicity:

Family/Whanau live in catchment area

Family/Whanau are Maori or Pasifika

Child/Tamariki is 3 to 4 years old

Child/Tamariki is not attending any Early Childhood Education service including Home-Based Education

Family/Whanau has low income status (Evidence e.g. receipt of income support or low wages can be provided)

Family/Whanau lack essential resources

Family/Whanau consent to referral

Child Youth and Family have been involved with family previously

Comments

St George's Preschool St Mary's Preschool Foundations for Learning Hippy

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