Welcome,

Connected Beginnings Child & Family Registration,

Thank you for registering with the Connected Beginnings Program.

Connected Beginnings supports Aboriginal children aged 0–5 years and their families by working alongside parents, carers, early childhood services, schools and health providers to improve children's health, development and school readiness.

The information you provide helps us understand your family's strengths and support needs so we can connect you with services where appropriate.

Section 1 - Child Information

Child First Name *

Child Last Name *

Child Preferred Name

Child Date of Birth *

Child Gender *

Child Gender Other

Child Aboriginal/Torres Strait Islander? *

Which community is Child from *

Child from other community

Does Child Live in Ngukurr *

Secton 2 - Parent Information

Parent/Carer name *

Relationship to Child *

Parent/Carer Date of Birth *

Parent/Carer Mobile Number *

Parent/Carer Alternate Number

Parent Email Address *

Preferred Language *

Interpreter Required? *

Section 3 - Household Information

Number of children in household *

Names and ages of siblings (optional)

Section 4 - Emergency Contact

Name *

Relationship to Child *

Phone Number *

Section 5 - Early Childhood Participation

Is your child currently attending? *

Name of Service/Institution *

Section 6 - Health and Development

Has your child had:
Questions

Health Check *

Hearing Check *

Vision Check *

Dental Check *

Developmental Check *

Section 7 - Parent Concerns

Section 8 - Current Services

Section 9 - Connected Beginnings Supports

Section 10 - Consent

Information Sharing

I give permission for Connected Beginnings to work with other organisations supporting my child.

Photography Consent
Can photographs of your child be used?

Internal reporting only *

Community newsletters/social media *

Communication

How would you like us to contact you?

PhoneSMSEmailMessenger Apps if appropriate

Section 11 - Privacy Statement

Your Privacy

Yugul Mangi Development Aboriginal Corporation (YMDAC) is committed to protecting your privacy and keeping your personal information safe.

The information collected in this registration form is used to:

register your family with the Connected Beginnings program;
provide services and support to you and your child;
coordinate services with your consent;
monitor and improve program outcomes; and
meet funding, reporting and legal obligations.

We will only collect information that is necessary to deliver the Connected Beginnings program.

Your personal information will be stored securely by YMDAC and will only be accessed by authorised staff. We will not share your information with other organisations unless:

you have provided your consent;
it is directly related to providing services to you or your child; or
we are required or authorised to do so by law.

YMDAC takes reasonable steps to protect your information from loss, misuse, unauthorised access, modification or disclosure.

You may request access to the personal information we hold about you or ask for corrections if any information is inaccurate or out of date. Requests should be made to YMDAC in writing.

If you have any questions about how your information is collected, used or stored, please contact YMDAC.

Section 12 - Declaration

I declare that the information I have provided is true and correct to the best of my knowledge. I understand that Connected Beginnings is a voluntary program and that I may choose to withdraw from the program at any time. I understand how my information will be collected, stored and used in accordance with YMDAC's Privacy and Confidentiality Policy.

Parent/Carer Name *auto filled from answer provided in section 2

Date Signed *

Digital Signature *

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