Registration Form Child 1 Registration Details

Transcription

1 Registration Form Child 1 Registration Details This form complete this if you wish to enrol your child(ren) into our School Age Care program. Please ensure all information is correct and where appropriate, corresponds exactly with information held by Centrelink. Missing information and or unrecognised information may result in you receiving no fee assistance through the Government s Childcare Benefit Scheme. Please question any point you are unclear about with the service s coordinator. First Name:...Middle Name: Last Name: Gender:Male Female D.O.B:. /../ CRN(Child Reference Number):(E.g X) Place of Birth:..School Attending: : Address: : Suburb: :..P/Code:... PCYC Membership Number:..Is your child Aboriginal or Torres Strait descent? Yes No Is your child attending another childcare centre service Yes No Swimming Ability: Good; Poor; None; Excellent Photograph or Media taken and used within the service and community: Within the Service Within the Community None Child 1 Medical Information Medicare Number:.Medical Centre Name: :Doctor Name:. Address: Suburb:.Phone:. Dentist Name:.. Address:.Phone: Does this child have Private Health Insurance? Yes No Private Health Insurer:. Does this child have permission to self administer medication? Yes No Office Use Only: Health Record has been sighted Has Child 1 been diagnosed at risk of Anaphylaxis? Yes No Any allergies: e.g. food, medication, animals or insects? Yes No Provide details:.. Any special dietary requirements? Yes No Any problems with hearing, sight or speech? Yes No Any health problems, operations, illnesses or disabilities? Yes No Does child 1 take any regular medication? Yes No Provide details:.. Provide details:.. Provide details:.. Provide details:. Does child 1 have a physical disability or delay, including intellectual, sensory or physical impairment? Yes No Provide details: Does either parent have a disability? Yes No Is the family a single parent family? Yes No OR is Child 1 NOT immunised? Yes Provide details: Birth 2 mths 4 mths 6 mths 12 mths 18 mths 4 yrs Hepatitis B Diphtheria Tetanus Pertussis Polio Hib Pneumococcal Rotavirus Measles Mumps - 1 -

2 If this portion of the Registration is not applicable please indicate by putting a line through it Child 2 Registration Details First Name:... Middle Name: Last Name:... Gender: Male Female D.O.B:./../ CRN(Child Reference Number): (E.g X) Place of Birth:.. School Attending: Address: Suburb:..P/Code:... PCYC Membership Number:.. Is your child Aboriginal or Torres Strait descent? Yes No Is your child attending another childcare centre service Yes No Swimming Ability: Good; Poor; None; Excellent Photograph or Media taken and used within the service and community: Within the Service Within the Community None Child 2 Medical Information Medicare Number: Medical Centre Name: :Doctor Name:. Address: Suburb:. Phone:. Dentist Name:.. Address:.Phone: Does this child have Private Health Insurance? Yes No Private Health Insurer:. Does this child have permission to self administer medication? Yes No Office Use Only: Health Record has been sighted Has Child 2 been diagnosed at risk of Anaphylaxis? Yes No Any allergies: e.g. food, medication, animals or insects? Yes No Provide details:.. Any special dietary requirements? Yes No Provide details:.. Any problems with hearing, sight or speech? Yes No Provide details:.. Any health problems, operations, illnesses or disabilities? Yes No Provide details:.. Does child 2 take any regular medication? Yes No Provide details:. Does child 2 have a physical disability or delay, including intellectual, sensory or physical impairment? Yes No Provide details: Does either parent have a disability? Yes No Provide details: Is the family a single parent family? Yes No OR is Child 2 NOT immunised? Yes Birth 2 mths 4 mths 6 mths 22 mths 28 mths 4 yrs Hepatitis B Diphtheria Tetanus Pertussis Polio Hib Pneumococcal Rotavirus Measles Mumps - 2 -

3 If this portion of the Registration is not applicable please indicate by putting a line through it Child 3 Registration Details First Name:... Middle Name: Last Name:... Gender: Male Female D.O.B:./../ CRN(Child Reference Number):..(E.g X) Place of Birth:.... School Attending: Address: Suburb: :..P/Code:... PCYC Membership Number:.. Is your child Aboriginal or Torres Strait descent? Yes No Is your child attending another childcare centre service Yes No Swimming Ability: Good; Poor; None; Excellent Photograph or Media taken and used within the service and community: Within the Service Within the Community None Child 3 Medical Information Medicare Number :. Medical Centre Name: :Doctor Name:. Address: Suburb:. Phone:. Dentist Name:.. Address:.Phone: Does this child have Private Health Insurance? Yes No Private Health Insurer:. Does this child have permission to self administer medication? Yes No Office Use Only: Health Record has been sighted Has Child 3 been diagnosed at risk of Anaphylaxis? Yes No Any allergies: e.g. food, medication, animals or insects? Yes No Provide details:.. Any special dietary requirements? Yes No Provide details:.. Any problems with hearing, sight or speech? Yes No Provide details:.. Any health problems, operations, illnesses or disabilities? Yes No Provide details:.. Does child 3 take any regular medication? Yes No Provide details:. Does child 3 have a physical disability or delay, including intellectual, sensory or physical impairment? Yes No Provide details: Does either parent have a disability? Yes No Provide details: Is the family a single parent family? Yes No OR is Child 3 NOT immunised? Yes Birth 3 mths 4 mths 6 mths 33 mths 38 mths 4 yrs Hepatitis B Diphtheria Tetanus Pertussis Polio Hib Pneumococcal Rotavirus Measles Mumps - 3 -

4 If this portion of the Registration is not applicable please indicate by putting a line through it Child 4 Registration Details First Name:... Middle Name: Last Name:... Gender: Male Female D.O.B:./../ CRN(Child Reference Number):..(E.g X) Place of Birth:.... School Attending: : Address: : Suburb: :..P/Code:... PCYC Membership Number:.. Is your child Aboriginal or Torres Strait descent? Yes No Is your child attending another childcare centre service Yes No Swimming Ability: Good; Poor; None; Excellent Photograph or Media taken and used within the service and community: Within the Service Within the Community None Child 4 Medical Information Medicare Number:. Medical Centre Name: :Doctor Name:. Address: Suburb:. Phone:. Dentist Name:.. Address:.Phone: Does this child have Private Health Insurance? Yes No Private Health Insurer:. Does this child have permission to self administer medication? Yes No Office Use Only: Health Record has been sighted Has Child 4 been diagnosed at risk of Anaphylaxis? Yes No Any allergies: e.g. food, medication, animals or insects? Yes No Provide details:.. Any special dietary requirements? Yes No Provide details:.. Any problems with hearing, sight or speech? Yes No Provide details:.. Any health problems, operations, illnesses or disabilities? Yes No Provide details:.. Does child 4 take any regular medication? Yes No Provide details:. Does child 4 have a physical disability or delay, including intellectual, sensory or physical impairment? Yes No Provide details: OR is Child 4 NOT immunised? Yes Birth 2 mths 4 mths 6 mths 42 mths 48 mths 4 yrs Hepatitis B Diphtheria Tetanus Pertussis Polio Hib Pneumococcal Rotavirus Measles Mumps - 4 -

5 Parent Guardian 1 - Registration Details First Name:... Middle Name: Last Name:... Gender: Male Female D.O.B:. /../ CRN(Child Reference Number):.. (E.g X)Place of Birth: Address: Suburb: P/Code: Home Phone:... Work Phone:.. Mobile:. . Occupation:.. Place of Work:... Work Starts:.. Work Finishes:.. Language spoken at home: Preferred method of contact:home Phone Mobile Do you have a disability? Yes No Provide details: Are you of Aboriginal or Torres Strait descent? Yes No Are you the primary carer of children indicated in registration? Yes No Will any accounts be paid by a third party? Yes No Provide details:.. Parent Guardian 2 - Registration Details First Name:... Middle Name: Last Name:... Gender: Male Female D.O.B:. /.. / CRN(Child Reference Number):.. (E.g X) Place of Birth: Address:.Suburb:P/Code: Home Phone:... Work Phone:.. Mobile:. (Include in s) Occupation: Place of Work:... Work Starts:.. Work Finishes:.. Language spoken at home: Preferred method of contact:home Phone Mobile Do you have a disability? Yes No Provide details: Are you of Aboriginal or Torres Strait descent? Yes No. Are you the primary carer of children indicated in registration? Yes No Family Status Both Parents at home Yes No Shared Custody Yes No Sole Parent Yes No Other - Provide details: Custody Arrangements If you are separated or divorced, who has legal custody of the child/ren? Parent 1 Parent 2 Both Parent 1 Access Arrangements? Full Limited Provide Details:.. Parent 2 Access Arrangements? Full Limited Provide Details:.. Are there any court orders relating to the powers and responsibilities of the parents in relation to the child/ren or access to the child/ren? Yes No Provide details: Emergency Contacts & Authorisations Contact 1 Name: Relationship to child: Grandmother; Grandfather; Godparent; Stepmother Stepfather; Sister; Brother; Aunty; Uncle; Friend; Other Address:. Home Phone:... Work Phone:. Mobile:... In relation to child/ren listed in the registration Contact 1 can: Collect and Deliver child/ren to and from servicegive permission for excursions out of service Consent to medical treatment Give permission for child to travel by ambulance Give permission or request administration of medication Contacted in case of emergency - 5 -

6 Contact 2 Name: Relationship to child: Grandmother; Grandfather; Godparent; Stepmother Stepfather; Sister; Brother; Aunty; Uncle; Friend; Other Address:. Home Phone:... Work Phone:. Mobile:... In relation to child/ren listed in the registration Contact 2 can: Collect and Deliver child/ren to and from service Give permission for excursions out of service Consent to medical treatment Give permission for child to travel by ambulance Give permission or request administration of medication Contacted in case of emergency Formal How would you like to receive your invoice? Login/ ed Hard Copy How would you like to pay your accounts? IDebit Centrepay deduction How would you like to receive your notifications? Electronic Paper Terms and Conditions Please read and initial each statement listed Initial I have read, understand and agree to abide by the conditions stated in the latest edition of the Parent Handbook Agree to familiarize myself with the programs and inform staff if I do not wish for my child/ren to participate in a particular activity If Applicable understand my child/ren will be transported by bus or walk to and from school and excursions and I understand when fitted my Child will be required a seat belt. Children under 7 will be provided with a booster seat in a vehicle with 12 or less seats. Give permission for staff to apply sunscreen (30+). If my child has an allergy, I agree to provide a suitable sunscreen for my child Consent PCYC staff providing: a) first Aid; or where appropriate; b) administering such emergency medical treatment as is reasonably Necessary. Agree to collect or make arrangements for collection of my child/ren if he/she becomes unwell at the service. Agree to inform the School Age Care Service of other children attending Long Day Care/Family Day Care/In home Care or any other service Or any other service where CCB is provided. I must notify the School Age Care Service of any child changes that may occur. Consent for PCYC School Age to share/attain information with child/renschool Administration and staff on issues pertaining to my child/ren Agree to pay all fees (including excursion fees) of the days my child is successfully enrolled, regardless of whether my child is enrolled but does not attend. I agree that 48 hours notice of non-attendance must be given otherwise I will be charged for the booked sessions. Understand that fees are due and payable a minimum of one week in advance at all times, and I may be required to enter into a payment plan using our prescribed third party company idebit, if my fees are not paid or if I get in arrears Understand that my child/ren care can be cancelled if my fees fall into arrears by more then 7 days. PCYC reserves the right to refer any outstanding debt to its appointed external debt collection agency; and I will be responsible for all costs incurred. Understand that in the event my child/ren is sent home with a suspected infectious illness a medical clearance/certificate must be provided on return of my child/ren to the service (If applicable) give permission for my child/ren to play, under supervision, on the school-oval and/ or local park Should staff arrive at school to collect my child/ren and the child/ren is/are not in the designated area and I have not informed the service of my child/renabsence, agree to pay a $2.00 fee which will be charged to my account for each telephone call made to locate my child/ren Understand that my child/ren may be required to leave the service because of priority access considerations as detailed in the Child Care Service Handbook (Australian Government, Dept of Education, Employment and Workplace Relations Parent/Guardian Signature Print Name:.. Date: Privacy Statement: The Queensland Police-Citizens Youth Welfare Association values our members and the individuals who interact with and support us and will continue to protect the personal information which you entrust to us