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* 1. Please advise which Possums program you would like to enrol your child in:
Possums Playgroup 0-4 years - Tuesday or Thursday *waitlist

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* 2. Please share a little more about your family's interest in joining our homeschool co-op

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* 3. Details of Child: Full name, date of birth, gender

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* 4. Details of Parent / Guardian 1: Full name, address, phone, email, place of employment

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* 5. Details of Parent / Guardian 2: Full name, address, phone, email, place of employment

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* 6. Custody Arrangement (If Applicable)

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* 7. Child Development / Disability / Learning Difficulty / Medical Conditions: Please describe below if your child has any special needs that may effect their participation in our programs or groups.

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* 8. Please share a little about your child's / childrens Temperament

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* 9. Please note all Possums families are required to instigate and lead at least one activity and morning circle per term.

Do you agree to fulfill your caregiver leader contribution per term?

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* 10. We acknowledge that we have read all of the information provided on the Village Learning website, including the Current Programs & Term Fees and the Village Learning Values & Agreements.

We have provided all relevant information for our child in this Application Form and we understand that failure to disclose any information that may impact upon our child’s experience and participation in the Village Learning Programs could result in cancellation of the child's place.

We understand that fees are paid for the term in advance and are not subject to adjustment because of illness or absence, or refundable in the instance of withdrawal from Village Learning.

PLEASE SIGN YOUR FULL NAME/S BELOW:

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* 11. I the parent or caregiver, understand that during the Possums program, my child is to be fully supervised by me or another caregiver of my child/ren. I assume full responsibility for the safety and well being of my child/ren and all other members of my family and relieve Village Learning of any responsibility in the case of injury or death to my child or any other members of my family. 

PLEASE SIGN YOUR FULL NAME/S BELOW

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* 12. Best time for a follow up phone call

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