ECE Name: *    

ECE MOE Number: *    

Physical Address: *    

Physical Suburb: *    

Physical City: *    

Physical Postcode: *    

Region: *    

Email: *    

Contact name: *    

Job title: *    

Centre manager name: *    

Centre manager email: *    

Signing authority name (if different):    

Signing authority email (if different):    

How many children is your ECE licensed for? *   

On average, how many attend each day? *   

What percentage of centre roll would benefit from KidsCan support? *    

EQI Rating *    

Does your centre currently offer a food programme? *   

Does your centre have someone specifically allocated to prepare meals?    

Yes, I confirm ECE management is aware and in support of this application. *    

Would you be happy for KidsCan to contact your ECE in relation
to media articles focusing on the needs of your community?
Note: your answer will not affect the success of your application. *