SA08 (Version 11: September 2014) - Page 1 of 12

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1 Provider approval number: SA- (Office Use Only) Before you begin You must read the following information before completing and submitting this application form. Use this form to... Approved providers can apply for a service or temporary if they are unable to meet prescribed elements of the National Quality Standard or regulations in the Education and Care Services National Regulations 2011 (National Regulations). Applicants should refer to the resources available on the ACECQA website, including the Operational Policy Manual for Regulatory Authorities, for information about applications and how they are processed. Regulatory authorities may also have some additional information specific to that jurisdiction on their website. An application for a can be submitted at any time to the local regulatory authority. However, if it is submitted with an application for a service approval the will not be granted unless the service approval is granted. Regulatory authorities will assess applications on a case-by-case basis and make a determination within 60 days of receiving a valid application. Important Please make sure you need a before applying. There is no reason to apply for a if you are able to comply with the regulations. Do not apply because you think you may need one in the future. For example, before applying for a of qualification requirements, you should check whether educators at your service can be counted towards the relevant requirements. You can do this by checking: whether educators at your service hold an approved qualification, published on the lists on the ACECQA website whether any educators who are currently studying can be counted as actively working towards an approved qualification whether there are any jurisdiction specific provisions for educators who were recognised under a former law. Your application will not be assessed unless it includes all required information and payment of the application fee. To help make sure the regulatory authority can process your application quickly, make sure to attach evidence in support of your application. Before submitting your application, check your regulatory authority s website to see if additional information is required. An application can be submitted to your regulatory authority electronically using the NQA IT System or in hard copy. If submitting a hard copy application, please write clearly in BLOCK LETTERS. The signatory should initial any corrections to this form. Applications will be assessed by the regulatory authority in the state or territory where the service is located. Office use only: Approved Not Approved Date: (Version 11: September 2014) - Page 1 of 12 In Confidence, When Completed

2 Your obligations Before submitting this form, you must ensure you are familiar with the requirements and obligations set out in the Education and Care Services National Law* and National Regulations. If you require further information, or you are unsure about the information required by this form, visit ACECQA s website at or contact the regulatory authority in your state or territory for clarification. You must ensure the information set out in this form is complete and correct. Providing false or misleading information to ACECQA or the regulatory authority is an offence under the Education and Care Services National Law. Failure to comply may result in a financial penalty. *Note: all references to the Education and Care Services National Law in this form are to be read as a reference to the Education and Care Services National Law Act 2010 (Vic), as applied as a law of the state and territory where you are submitting this form. References to ACECQA are to the Australian Children s Education and Care Quality Authority, established under section 244 of the Education and Care Services National Law. Important Please write clearly in BLOCK LETTERS. Your application/notification will not be processed unless all sections are satisfactorily completed, all requested supporting documents are attached, and any prescribed fees are paid. Please submit all pages of this form to the regulatory authority. Many applications/notifications can be submitted to the regulatory authority electronically using the NQA IT System. If you want to submit your application electronically, visit the ACECQA website at Privacy statement Regulatory authorities and ACECQA are committed to ensuring all actions taken in the administration of the Education and Care Services National Law are in compliance with the information privacy principles of the Privacy Act 1988 (Commonwealth). Regulatory authorities and ACECQA are collecting the information on this form for the purpose of performing a function under the Education and Care Services National Law. The information on this form may also be provided to other authorities or to other government agencies in accordance with the Education and Care Services National Law. ACECQA, the regulatory authorities and the Australian Government may publish information about you in accordance with the Education and Care Services National Law. Office use only: Approved Not Approved Date: In Confidence, When Completed (Version 11: September 2014) - Page 2 of 12

3 Part A: Service details 1. Approved provider name: 2. Provider approval number: 3. Trading name of the service: 4. Please provide the address of the service: Address line 1: Address line 2: Suburb/town: State/territory: Postcode: 5. Service approval number: 6. Type of (s) sought: Service Temporary (not more than 12 months) (Version 11: September 2014) - Page 3 of 12

4 7. Please select the element/s of the National Quality Standard and the regulation/s that you are seeking a for. If applying to waive an element you must also specify the regulation. Note: Waivers are only available for the regulations and elements listed below. REGULATIONS/ELEMENTS THAT MAY BE COVERED BY A WAIVER FAMILY DAY CARE SERVICES P Reg/Quality Area (QA) Requirement Please specify which sub-regulation you are seeking to have waived, if applicable (e.g. 124(2)(a)) Physical environment 104 Fencing 107 Indoor space 108 Outdoor space 110 Ventilation and natural light 117 Glass QA3 Physical environment Please specify which element/s you are seeking to have waived Staffing 124 Number of children who can be educated and cared for 127 Family day care educator qualifications 128 Family day care coordinator qualifications 136 First aid qualifications (Temporary only) QA4 Staffing arrangements Please specify which element/s you are seeking to have waived Saving and transitional regulations Ch.7 Any jurisdiction-specific, transitional or saving regulations that apply in place of the regulations outlined above. Please specify which transitional or saving regulation (and sub-regulation, if applicable) you are seeking to have waived (e.g. 276(2)) (Version 11: September 2014) - Page 4 of 12

5 REGULATIONS/ELEMENTS THAT MAY BE COVERED BY A WAIVER CENTRE-BASED SERVICES P Reg/Quality Area (QA) Physical environment Requirement Please specify which sub-regulation you are seeking to have waived, if applicable (e.g. 126(1)(b)) 104 Fencing 107 Indoor space 108 Outdoor space 110 Ventilation and natural light 111 Administrative space 112 Nappy change facilities 113 Outdoor space natural environment 114 Outdoor space - shade 115 Premises designed to facilitate supervision QA3 Physical environment Please specify which element/s you are seeking to have waived Staffing 120 Supervision for educators under 18 years 123 Educator-to-child ratios 126 General educator qualifications 130 Early childhood teacher (fewer than 25 approved places) 131 Early childhood teacher (25 or more approved places, but fewer than 25 children) 132 Early childhood teacher (25 to 59 children) 133 Early childhood teacher (60 to 80 children) 134 Early childhood teacher (more than 80 children) 136 First aid qualifications (Temporary only) QA4 Staffing requirements Please specify which element/s you are seeking to have waived Saving and transitional regulations Ch.7 Any jurisdiction-specific, transitional or saving regulations that apply in place of the regulations outlined above. Please specify which transitional or saving regulation (and sub-regulation, if applicable) you are seeking to have waived (e.g. 343(2)) (Version 11: September 2014) - Page 5 of 12

6 Note: The examples below are illustrative only. Applications will be considered on a case-by-case basis and must include sufficient supporting evidence. 8. Please give reasons the education and care service cannot comply (or will not comply) with the specified elements or regulations: Examples: the service is required to have two diploma-qualified educators to comply with regulation 126(a), but one diploma-qualified educator has resigned and the approved provider has been unable to recruit a second diploma qualified educator the service does not have sufficient outdoor space to comply with regulation 108(2) and is unable to access or acquire additional outdoor space 9. Please give details and evidence of any attempts made to comply with the specified regulations: Examples: the service has advertised in the local newspaper and on seek.com, but has not had any suitable applicants (copies of advertisements attached) there is no additional suitable outdoor space available to the service (copy of plans or map of service location attached) Types of evidence For applications for a of qualification requirements, you can attach the following types of evidence to demonstrate your attempts to comply: copies of advertisements for qualified staff in mainstream publications, including websites if an educator is studying towards an approved qualification, copies of their transcript transcripts or parchments for any other qualifications held by an educator that are relevant to children s education and care contact with agencies that offer qualified relief staff mentoring between qualified and unqualified educators if an educator has a qualification awarded overseas, evidence that they have applied to ACECQA for assessment of equivalence with an approved qualification links with other services or local training organisations. Attaching evidence to support your application will help ensure it is processed quickly by the regulatory authority. (Version 11: September 2014) - Page 6 of 12

7 10. Please detail the steps being taken (or steps that will be taken) to protect the wellbeing of children being cared for by the service while the is in force: Examples: the service has employed another approved certificate III level qualified educator (copy of academic transcript attached), and has established a mentoring relationship between the diploma and certificate III qualified educators the service will conduct daily excursions (weather permitting) to the nearby park, and will increase elements of the natural environment in the indoor space at the service (map showing location of park, and sample of parents authorisation for the regular outing attached) FOR TEMPORARY WAIVER APPLICATIONS ONLY: Note: If you re not applying for a temporary, go to question Please state the period for which a temporary is sought (not more than 12 months) and the reasons for seeking that period of time: Example: the service is seeking a for three months so it can enrol a certificate III level educator in an approved diploma course (details of course start date attached) (Version 11: September 2014) - Page 7 of 12

8 Part A: Service details - continued 12. Please detail the steps that will be taken while the is in force, so the service will comply with the elements or regulations by the time the expires: Example: the service is supporting an approved certificate III level educator to obtain an approved diploma level qualification, so that it can comply with regulation 126(1)(a) by the time the expires (statement of enrolment attached) ALL APPLICANTS: 13. Name and contact details for this notification: Note: This will be the person whom the regulatory authority will contact for questions relating to this notification. Details Title: Last name: Phone number: First name: Mobile number: Fax number: Postal address Address line 1: Address line 2: Suburb/Town: State/ Territory: Postcode: (Version 11: September 2014) - Page 8 of 12

9 Part B: Declaration Who may sign? Individuals: the individual applicant/notifier Company: two directors of the company, or a director and company secretary, or if a sole proprietor, the sole director Incorporated association: the public officer and one other member of the management committee Cooperative: two directors of the cooperative, or a direct and one other officer of the cooperative Partnership: a managing partner who is authorised to sign on behalf of the partnership Corporation: signed in a accordance with the rules of the corporation Government school council: signed in accordance with the rules of the council. I, [inser t full name of person signing the declaration] of, [insert address], am position/title of applicant (for example, proprietor, director, partner, president)]. [insert and I am the approved provider of the service, or a person authorised to sign on the approved provider s behalf. Note: please tick one box only I declare that: 1. the information provided in this form (including any attachments) is true, complete and correct 2. I have read, understood and agree to the conditions and the associated material contained in this form 3. I understand that the regulatory authority and/or ACECQA have the right (but are not obliged) to act in reliance upon the contents of this form, including its attachments 4. I have read and understood a provider s legal obligations under the Education and Care Services National Law 5. the regulatory authority is authorised to verify any information provided in this form 6. some of the information provided in this form may be disclosed to the Commonwealth for the purposes of the Family Assistance Law and may be disclosed to other persons/authorities where authorised by the Education and Care Services National Law or other legislation, and 7. I am aware that under the Education and Care Services National Law penalties apply if false or misleading information is provided. Signature of person making the declaration: Signed at: on the Note: If necessary, please complete the second declaration over the page. (Version 11: September 2014) - Page 9 of 12

10 Second signatory (if required) I, [inser t full name of person signing the declaration] of, [insert address], am position/title of applicant (for example, proprietor, director, partner, president)]. [insert I declare that: 1. the information provided in this form (including any attachments) is true, complete and correct 2. I have read, understood and agree to the conditions and the associated material contained in this form 3. I understand that the regulatory authority and/or ACECQA have the right (but are not obliged) to act in reliance upon the contents of this form, including its attachments 4. I have read and understood a provider s legal obligations under the Education and Care Services National Law 5. the regulatory authority is authorised to verify any information provided in this form 6. some of the information provided in this form may be disclosed to the Commonwealth for the purposes of the Family Assistance Law and may be disclosed to other persons/authorities where authorised by the Education and Care Services National Law or other legislation, and 7. I am aware that under the Education and Care Services National Law penalties apply if false or misleading information is provided. Signature of person making the declaration: Signed at: on the (Version 11: September 2014) - Page 10 of 12

11 Part C: Payment details The fee required to be paid with an application for a service or temporary is $104. Note: The regulatory authority can waive/defer/refund fees in particular circumstances Payment by credit card To pay your fees by credit card, complete the details below. Amount: Card type: Mastercard Visa Card expiry date: / MM/YY Card number: Credit card CVN* *CVN is the 3 digit security code found on the back of Mastercard and Visa credit cards Name on card: Cardholder s signature: Payment by cheque or money order Note: Payment by cheque or money order is not accepted by the NSW Regulatory Authority. Please make your cheque or money order payable to the relevant regulatory authority: ACT: NT: QLD: SA: TAS: VIC: WA: Education and Training Directorate Receiver of Territory Monies Department of Education, Training and Employment Education and Early Childhood Services Registration and Standards Board Department of Education Department of Education and Early Childhood Development Department of Local Government and Communities (Version 11: September 2014) - Page 11 of 12

12 Submitting this form Please submit this form along with any required documentation to the relevant regulatory authority. Australian Capital Territory Children s Policy and Regulation Unit Education and Training Directorate GPO Box 158 CANBERRA CITY ACT 2601 Fax: (02) cpru@act.gov.au Phone: (02) Website: New South Wales NSW Early Childhood Education and Care Directorate Locked Bag 5107 PARRAMATTA NSW 2124 Fax: (02) ececd@det.nsw.edu.au Phone: (toll free) Website: Northern Territory Quality Education and Care NT Department of Education GPO Box 4821 DARWIN NT 0801 Fax: (08) qualityecnt.det@nt.gov.au Phone: (08) Website: Queensland Early Childhood Education and Care Department of Education, Training and Employment PO Box CITY EAST QLD 4002 Fax: (07) ecec@dete.qld.gov.au ecec@dete.qld.gov.au Phone: 13 QGOV ( ) * Website: * Calls from mobiles are charged at applicable rates South Australia Education and Early Childhood Services Registration and Standards Board of South Australia GPO Box 1811 ADELAIDE SA 5001 Fax: (08) EECSB.NationalQualityFramework@sa.gov.au Phone: (toll free) Website: Tasmania Department of Education Education and Care Unit GPO Box 169 HOBART TAS 7001 Fax: (03) ecu.comment@education.tas.gov.au Phone: Website: Victoria Department of Education and Early Childhood Development Quality Assessment and Regulation Division GPO Box 4367 MELBOURNE VIC 3001 Fax: (03) licensed.childrens.services@edumail.vic.gov.au Phone: Website: Western Australia Department of Local Government and Communities Education and Care Regulatory Unit PO Box 6242 East Perth Business Centre EAST PERTH WA 6892 Fax: (08) ecru@dlgc.wa.gov.au ecru@dlgc.wa.gov.au Phone: (08) Website: (Version 11: September 2014) - Page 12 of 12