QBN Parents Group - Enrolment Form

The QBN Parents Group is a fun and non-judgemental space for young parents as well as first time parents.

When: 10–11:30am Wednesdays during school term.

Where: Axis Youth Centre, next to Queanbeyan Central Park and Playground.

For more information, contact us on community.team@qprc.nsw.gov.au

Family Details

Parent/Carer

Full name *

Date of birth *

Gender *

Address *

Street address *

City *

State *

Postcode *

Phone number *

Email Address *

Birth Country *

Do you identify as Aboriginal and/or Torres Islander? *

Do you have stable accommodation? *

YesNo

Are you a sole parent? *

YesNo

Do you and/or your child have a health condition or disability?

YesNo

If yes, please provide more information

Do you or your child have an Emergency Action Plan?

YesNo

Please provide a copy of your Emergency Action Plan *

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What language do you speak at home? *

Allergies/Special diets

How did you hear about this group?

Child's details

Child's full name *

Child's gender *

Child's date of birth *

Does your child identify as Aboriginal and/or Torres Strait Islander *

Is the address the same as above? If not, provide details

Emergency contact

Please nominate a person (other than parents/carer) to contact in case of emergency.

Full name of emergency contact *

Contact number for emergency contact *

Relationship *

Permission/Consent

I give consent to photos of myself and my child/ren being used for promotional purposes (on Campbell Page or QPRC webpages, social media or flyers)? *

YesNo

I would like to be contacted for survey/research/evaluation *

YesNo

I give my consent to seek medical assistance/advice in case of an emergency *

YesNo

The personal information collected on this form is stored in a data Exchange IT system hosted by the Australian Government Department of Social Services. All personal information is de-identified, which means that DSS removes information that identifies you or could be used to re-identify you (e.g. your name). This data is collected to assist with policy development, grant programs, research and evaluation. You can find more information about how DSS will manage your personal information in the DSS privacy policy on their website: https://www.dss.gov.au/privacy-policy.

Do you consent to:

Information on this form to be stored on the Data Exchange? *

YesNo

I would like a copy of the Department of Social Services Data Exchange “Information on Privacy” form *

YesNo

Parent/Guardian signature *

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By submitting this form you agree to your personal information being collected and stored by QPRC for the purpose of providing this program.