Current Parent declaration Family details Consent Complete Indicates required field Parent declaration - self referral I understand that this form is used to collect information about my family to support kindergarten registration and/or kindergarten enrolment in Bendigo. I understand that the information provided will be used by the City of Greater Bendigo Kindergarten Outreach Program to support my family to register with Loddon Mallee Preschool Association (LMPA) and enrolment with a Bendigo Kindergarten. I understand that information shared maybe discussed with LMPA and the City’s Maternal and Child Health Team. Loddon Mallee Preschool Association Name Parent/carer name Date Signature Use your mouse or finger to draw your signature above Family details Child's name Date of birth Parent/carers name Parent/carers name relationship to child Parent/carers address Parent/carers contact number Parent/carers address email address Do you require an interpreter? Yes No What language is required? Consent I agree to give consent to the City to have my contact details for kindergarten registration (where applicable) enrolment. Name Signature Use your mouse or finger to draw your signature above Leave this field blank