Prospective Educator Expression of Interest Prospective Educator Expression of Interest Step 1 of 5 20% Educator DetailsFull Name First Last SexMaleFemaleThird ChoiceDate of Birth Contact NumberEmail Address Residential Address Street Address Address Line 2 City State Post Code Country of BirthAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabweCultural BackgroundAboriginalTorres Strait IslanderOtherLanguages spoken at homePartners DetailsFull Name First Last Date of Birth Contact NumberCountry of BirthAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabweCultural BackgroundAboriginalTorres Strait IslanderOtherLanguages spoken at homeOccupationStart Time : HH MM AM PM Finish Time : HH MM AM PM Children's Details Child 1Full Name First Last Date of Birth Lives at HomeYesNo Child 2Full Name First Last Date of Birth Lives at HomeYesNo Child 3Full Name First Last Date of Birth Lives at HomeYesNo Child 4Full Name First Last Date of Birth Lives at HomeYesNoOther people residing at the residenceFull Name First Last Date of Birth Relationship to youCommentsFull Name First Last Date of Birth Relationship to youComments Availability - Days and HoursMondayTuesdayWednesdayThursdayFridaySaturdaySunday How many children (including your own children) would you be available to care for?What age group are you interested in caring for?0 - 2 Years3 - 5 Years5 - 12 YearsWhat type of care are you able to provide?Full timePart-timeBefore and After SchoolOvernightOccasional CareReliefWeekend FIt and Proper PersonDo you or anyone residing at your premises smoke?YesNo Medical Condition: A medical certificate is required prior to approval. Does anyone residing with you have any medical health problems which may affect your ability to adequately care and supervise children?YesNoPlease CommentQualifications & TrainingQualifications Cartificate III Diploma Bachelor/Degree Ceritificate III - Date of Completion Diploma - Date of Completion Bachelor/Degree - Date of Completion Training CPR First Aid Asthma Management Anaphylaxis Child Protection CPR - Date of Completion First Aid - Date of Completion Asthma Management - Date of Completion Anaphylaxis - Date of Completion Child Protection - Date of Completion EmploymentAre you currently employed?YesNoDetails of current or previous employment Have you ever been registered with a Family Day Care Scheme?YesNoName of the schemeHave you ever been deregistered from a Family Day Care Scheme?YesNoGive ReasonEnvironmentDwellingOwnedRentedDept. of HousingBody CorporateDo you have a fully fenced outside play area?YesNoDo you have a pond, dam or swimming pool?YesNoDo you have any pets?YesNoPlease ListWhy do you want to operate a FDC business?What skills and experience do you have in relation to working with children?How will you maintain records required for running a business?What do you believe is the role of a FDC educator?How will you ensure compliance with the National Quality Standards? RefereesPlease provide name and contact details of 2 people willing to provide references for you. At least one reference should be related to your work with children. Your referees should not be related to you. You must inform your referees that they will be contacted from Collective FDCFull Name First Last Address Street Address Address Line 2 City State Post Code RelationshipPhoneFull Name First Last Address Street Address Address Line 2 City State Post Code RelationshipPhoneDeclarationI certify that the information provided in this application is true and correct.*Date This iframe contains the logic required to handle AJAX powered Gravity Forms.
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