SCAN Program (Supporting Children with Additional Needs)
Supplementary support for preschools
(Individual child)
Application Form
(to be completed by the preschool)
Preschool Details
Preschool Name:
Contact Person:
Telephone:
Child Details
First Name:
Last Name:
Date of Birth:
Gender: 
Male
 Female
Residential Postcode:
Background of Child
 Low income
 Additional English language need
 Aboriginal
Days of Attendance
Monday
Tuesday
Wednesday
Thursday
Friday
Monday
Tuesday
Wednesday
Thursday
Friday
AM
PM
Days Funded by the
SCAN Program to
Support Attendance
(completed by SCAN
Organisation, when
applicable)
AM
PM
Start date at preschool
……../………../…………
Start date for SCAN support
……../………../…………
(funding is limited to a maximum of two and a half days per week (15 hours) per child, and will be paid on a
half day or full day basis)
Date left preschool
……../………../………… (completed by SCAN Organisation when applicable)
Date left for SCAN support
……../………../………… (completed by SCAN Organisation when applicable)
KU Northern Sydney SCAN, Box Q132, QVB Post Office NSW 1230
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Child’s Name:
What is the child’s
primary diagnosis (as
per the child’s report)
Please tick the
Disability Type that
best describes the
primary diagnosis
Name of Professional
who made the
Diagnosis
Professional’s Role
 Severe Behaviour Disability
 Severe Social Emotional Disability
 Delayed Developmental or Diagnosed Disability
 Severe Chronic Health Condition
 GP
 Psychologist
 Speech Pathologist
 Moderate to Severe Language Delay
 Paediatrician
 Psychiatrist
 Audiologist
 Professional qualified to administer psychometric assessments
 Medical specialist (e.g. physiotherapist, occupational therapist)
 Early childhood teacher with an additional qualification in Special Education not
working with the child and not employed by the preschool that the child attends
 Primary teacher with an additional qualification in Special Education not
working with the child and not employed by the preschool that the child attends
Please indicate the
qualification of the
support worker who
will be working with
your team to support
the child’s inclusion
Please detail the child’s strengths and interests, and nature of additional needs:
Strengths
Interests
Needs
KU Northern Sydney SCAN, Box Q132, QVB Post Office NSW 1230
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Child’s Name:
Funding for individual applications will be determined by the need for adjustments in each of the
following areas of your preschool to assist the child to access the program.
Social
Environment
Staffing
Programming
Needs of other
children
Physical
Environment
KU Northern Sydney SCAN, Box Q132, QVB Post Office NSW 1230
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Child’s Name:
If you are requesting Exceptional circumstances funding please complete and attach the
Exceptional circumstances funding application form.
Exceptional circumstances funding:  Yes
 No
Documents to be attached:
Signed copy of assessment/diagnosis
Signed parent consent form
I certify that the information provided in this application is true and accurate
Nominated Supervisor’s Name: _________________________________________________________
Signature: ___________________________________________ Date: _________________________
KU Northern Sydney SCAN, Box Q132, QVB Post Office NSW 1230
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