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Family day care cancellation of child care form

Complete this form when a child in your care is leaving your service.

Educator details

Scheme name (required)

-- Please Select --Central MetroCountry CentralEastern DistrictsEastern EyreFar NorthHills MurraylandsNorth MetroNorthsideSouth East RiverlandSouthern DistrictsSouthern ValesWest Country

Is the child also enrolled in your respite care program? (required)

• yes
• no

Is the child also enrolled in your guardianship family day care service? (required)

• yes
• no

Educator’s first name (required)

Educator’s last name (required)

Educator’s email (required)

Cancellation details

Parent or carer's first name (required)

Parent or carer's last name (required)

Number of children (required)

-- Please Select --1234

Child 1

Child's first name

Child's last name

Last day of care

Day 12345678910111213141516171819202122232425262728293031 Month JanFebMarAprMayJunJulAugSepOctNovDec Year 202220232024202520262027202820292030203120322033203420352036203720382039204020412042204320442045204620472048204920502051205220532054205520562057205820592060206120622063206420652066206720682069207020712072207320742075207620772078207920802081208220832084208520862087208820892090209120922093209420952096209720982099

Child 2

Child's first name

Child's last name

Last day of care

Day 12345678910111213141516171819202122232425262728293031 Month JanFebMarAprMayJunJulAugSepOctNovDec Year 202220232024202520262027202820292030203120322033203420352036203720382039204020412042204320442045204620472048204920502051205220532054205520562057205820592060206120622063206420652066206720682069207020712072207320742075207620772078207920802081208220832084208520862087208820892090209120922093209420952096209720982099

Child 3

Child's first name

Child's last name

Last day of care

Day 12345678910111213141516171819202122232425262728293031 Month JanFebMarAprMayJunJulAugSepOctNovDec Year 202220232024202520262027202820292030203120322033203420352036203720382039204020412042204320442045204620472048204920502051205220532054205520562057205820592060206120622063206420652066206720682069207020712072207320742075207620772078207920802081208220832084208520862087208820892090209120922093209420952096209720982099

Child 4

Child's first name

Child's last name

Last day of care

Day 12345678910111213141516171819202122232425262728293031 Month JanFebMarAprMayJunJulAugSepOctNovDec Year 202220232024202520262027202820292030203120322033203420352036203720382039204020412042204320442045204620472048204920502051205220532054205520562057205820592060206120622063206420652066206720682069207020712072207320742075207620772078207920802081208220832084208520862087208820892090209120922093209420952096209720982099

More information if required

Enter more details here...

Check above information

Please check all data is true and correct.

By submitting this form, you declare all information to be true and correct on 19 April 2024.