Program details Program Supported Playgroup In-Home Support Both Supported Playgroup and In-Home Support Playgroup - None -Sara Court PreschoolCameron Street PreschoolTraffic School PlaygroupYallourn North Playgroup Parent Details Parent Full Name Gender - Select -MaleFemaleIndeterminate/Intersex/Unspecified Date of Birth Best Contact Number Email Address Home Address Aboriginal or Torres Strait Islander - Select -YesNo Relationship to children Main language at home Country of Birth If born outside of Australia, what year did you arrive? Family Status - Select -SingleMarried/Defacto Do you need an interpreter? - Select -YesNo Highest level of education - Select -Some High SchoolCompleted High SchoolTAFE Certificate or DiplomaUni/Tertiary Degree Are you or anyone in your family household a primary carer, holds a Health Care Card or a Visa? - Select -NoYes, I doYes, a household member Have you used the Enhanced Maternal and Child Health service in the past or currently? - Select -NoYes Where did you find out about this program? - Select -Social Media/Online/FriendMaternal and Child Health NurseDoctorCommunity Services AgencyChildFIRST/Child Protection Approximately how many books do you have in the home? - Select -Less than 1010-30More than 30 I consent to Latrobe City Council taking photos and video to use in promotional material or occasionally provide to state or federal government. Emergency Contact Contact Name Best Contact Number Relationship to enrolling parent Child 1 Child's Given Name Child's Surname Child's Date of Birth Child's Gender - Select -FemaleMaleIndeterminate/Intersex/Unspecified Aboriginal or Torres Strait Islander - Select -YesNo In kinship (out of home) care - Select -YesNo Diagnosed with a developmental delay or disability - Select -YesNo If yes, provide details Relevent medical information Up-to-date with Maternal Child Health visits - Select -YesNo, but will be at the end of termNo Enrolled in 4 year old kindergarten - Select -YesNo, but will be at the end of termNot eligible, won't be 4 years old on 30 April 2019No Enrolled in early start kindergarten - Select -YesNo but will be at the end of termNoNot eligible Do you have another child to enrol in the program? Yes No Child 2 Child's Given Name Child's Surname Child's Date of Birth Child's Gender - None -FemaleMaleIndeterminate/Intersex/Unspecified Aboriginal or Torres Strait Islander - None -YesNo In kinship (out of home) care - None -YesNo Diagnosed with a developmental delay or disability - None -YesNo If yes, provide details Relevent medical information Up-to-date with Maternal Child Health visits - None -YesNo, but will be at the end of termNo Enrolled in 4 year old kindergarten - None -YesNo, but will be at the end of termNot eligible, won't be 4 years old on 30 April 2019No Enrolled in early start kindergarten - None -YesNo but will be at the end of termNoNot eligible Do you have a third child to enrol in the program? Yes No Child 3 Child's Given Name Child's Surname Child's Date of Birth Child's Gender - None -FemaleMaleIndeterminate/Intersex/Unspecified Aboriginal or Torres Strait Islander - None -YesNo In kinship (out of home) care - None -YesNo Diagnosed with a developmental delay or disability - None -YesNo If yes, provide details Relevent medical information Up-to-date with Maternal Child Health visits - None -YesNo, but will be at the end of termNo Enrolled in 4 year old kindergarten - None -YesNo, but will be at the end of termNot eligible, won't be 4 years old on 30 April 2019No Enrolled in early start kindergarten - None -YesNo but will be at the end of termNoNot eligible Thinking about your parenting Focussing on child/ren participating in the playgroup with you: Questions Strongly disagree Disagree Mixed feelings Agree Strongly agree When something goes wrong between me and my child, there is little I can do to fix it Strongly disagree Disagree Mixed feelings Agree Strongly agree I know how to solve most problems that arise with parenting Strongly disagree Disagree Mixed feelings Agree Strongly agree I have confidence in myself as a parent Strongly disagree Disagree Mixed feelings Agree Strongly agree My child usually ends up getting their own way, so why try Strongly disagree Disagree Mixed feelings Agree Strongly agree I have the skills to deal with new situations with my child as they arise Strongly disagree Disagree Mixed feelings Agree Strongly agree When changes are needed in my family I am good at setting goals to achieve those changes Strongly disagree Disagree Mixed feelings Agree Strongly agree I can find out what’s needed to resolve any problems my child has Strongly disagree Disagree Mixed feelings Agree Strongly agree I meet my expectations for providing emotional support for my child Strongly disagree Disagree Mixed feelings Agree Strongly agree I often feel helpless about my child’s behaviour Strongly disagree Disagree Mixed feelings Agree Strongly agree I am good at making plans and arranging fun and educational activities for my child to engage in Strongly disagree Disagree Mixed feelings Agree Strongly agree I have all the skills necessary to be a good parent to my child Strongly disagree Disagree Mixed feelings Agree Strongly agree I know I am doing a good job as a parent Strongly disagree Disagree Mixed feelings Agree Strongly agree I know how to work out which situations my child is likely to be happiest in Strongly disagree Disagree Mixed feelings Agree Strongly agree I can stay focused on the things I need to do as a parent even when I've had an upsetting experience Strongly disagree Disagree Mixed feelings Agree Strongly agree My parenting skills are effective Strongly disagree Disagree Mixed feelings Agree Strongly agree How my child turns out is mainly due to luck Strongly disagree Disagree Mixed feelings Agree Strongly agree Thinking about what happens in your home In a typical week, how often do you do the following with your child: Questions Not at all 1-2 times a week 3-6 times a week Everyday Play music, sing songs, or do other musical activities? Not at all 1-2 times a week 3-6 times a week Everyday Tell stories to your child? Not at all 1-2 times a week 3-6 times a week Everyday Read books to your child? Not at all 1-2 times a week 3-6 times a week Everyday Play indoors with toys or games with your child? Not at all 1-2 times a week 3-6 times a week Everyday Involve your child in everyday activities at home, such as cooking or caring for pets? Not at all 1-2 times a week 3-6 times a week Everyday Play with your child in the bath? Not at all 1-2 times a week 3-6 times a week Everyday Play finger/rhyming games with your child (e.g. eensy weensy spider)? Not at all 1-2 times a week 3-6 times a week Everyday Play peek-a-boo or hide and seek with your child? Not at all 1-2 times a week 3-6 times a week Everyday Talk about the day while your child is eating? Not at all 1-2 times a week 3-6 times a week Everyday Leave this field blank
