(SERVICE NAME) ENROLMENT FORM

Transcription

1 (SERVICE NAME) ENROLMENT FORM Thank you for choosing a Lentara Uniting Care Children s Services Program. Please read and complete all sections of this form carefully. This information is required under the Education and Care Services National Regulations 2012 and is vital to the safety and wellbeing of your child. This form must be completed in full to be accepted. Date of Enrolment: Group 3 Year Old Kindergarten 4 Year Old Kindergarten Child Care: Age Group: Information about your Child Family Given Residential Suburb: Who does the child live with? (Please circle) Mother only Father only Both Parents Guardian Date Of Birth: Preferred Postcode: Gender of Child: Female / Ma Child s Country Of Birth? Languages spoken in the home? Religion/Cultural Background Is your child of Aboriginal or Torres Strait Islander background? If yes, Please Circle Does your Child/Family hold a: (Please provide a copy of the document) Health Care Card (HCC) Pensioner Care Card (PCC) Veteran s Affairs Gold Card Veteran s Affairs White Card Temporary Protection/Humanitarian Visa Refugee/Special Humanitarian Visa Asylum Seeker Bridging Visa Aboriginal / Torres Strait / Both Reference Number: Expiry Date: Sighted: Parent and Guardian Information: (A person who is authorised to authorise an educator to take child outside the education and care service premises) CRN: CRN: Full Date of Birth (Childcare only ) Address If different from Child Occupation: Country of birth Telephone/s: Full Date of Birth (Childcare only ) Address If different from Child Occupation: Country of birth: Telephone/s: Home: Work: Mobile: Home: Work: Mobile:

2 How do you prefer to receive information/correspondence? Please circle: Letters AGE AND NAME OF SIBLINGS or extended Family living in the home (optional) Name Age Sex Does this child attend an approved Early childhood service where CCB is claimed? EMERGENCY CONTACTS (persons other than parents/guardians) Please complete all details of other person/s authorised to collect and care for your child in the event of an emergency, consent to the medical treatment of the child and request or permit the administration of medication to the child; If you cannot be contacted. Please advise this person/s that you have nominated and authorised them and that they should be available to do so when required. Photo identification will be required on arrival at the service. Contact name: Business phone: Home Phone: Mobile: Child s Doctor/Medical Centre: Telephone: Ambulance Cover: Has your child been hospitalised? If so, for what condition? Contact name: Business phone: Home Phone: Mobile: Medicare Number: Private Health Details: Does your child require any additional support to participate in the program? Yes If so, please list: No DETAILS OF CHILD S ALLERGIES OR MEDICAL CONDITIONS Does your child have any medical conditions and needs? e.g. asthma, epilepsy, diabetes, other. Yes No If yes, please list and provide a Medical Management Plan completed and signed by your medical practitioner. Does your child have any allergy or sensitivity? e.g. Insect bites, food, anaphylaxis etc. Yes No If Yes, please specify? Is your child at risk of Anaphylaxis? Yes No If yes, please provide an Anaphylaxis Management Plan completed and signed by your medical practitioner. A risk minimisation plan will need to be completed in conjunction with the educators for all medical conditions.

3 CHILD S IMMUNISATION RECORD Has the child been immunised? Yes No Name of educator that sighted the record: Date sighted: / / If yes, provide the details by: attaching a copy of the Immunisation Record from the Child Health Record book OR attaching the Child History Statement from the Australian Childhood Immunisation Register Collaborative Partnerships: In order for you and your child to have the best possible early childhood experience please detail any other professionals your child or family is currently working with ie: Enhanced Maternal Child Health, Family Support etc. Agency: Contact Contact Number: Agency: Contact Contact Number: OTHER PERSONS WITH AUTHORITY TO COLLECT THE CHILD (Authorised Nominee) Your consent is required for other people to collect your child from the service on your behalf. I/we authorise the following other people to collect our child/children. Photo identification will be required upon collection of child/children. Phone No: Phone No: COURT ORDERS relating to the child. Are there any court orders relating to the powers and responsibilities of the parents/guardian in relation to the child or access to the child? No Yes Go to the next section Please complete the following 1. Bring the original court order/s signed by the magistrate for staff to sight and copy to attach to this enrolment form; 2. If at any stage changes are made to the court orders, you must provide the service with an updated copy immediately. ATTENDANCE AT OTHER CARE SERVICES Does this child attend any other services during the week? Yes No If so, which one: Please fill in table below: Day Service Times Monday Tuesday Wednesday Thursday Friday Is there any additional information you wish to share with us relating to your child and family? i.e. Religion, food restrictions, special interests/ talents/ fears/ concerns/ aspirations Would you be interested in volunteering on the Parent Advisory Committee (PAC)? Yes No

4 SUNSCREEN I give permission for Service to apply SPF 30+ sunscreen: Yes No If no, I will provide my own sunscreen: Yes No PHOTOGRAPHS / VIDEOS / CELEBRATIONS Do you agree to your child being photographed/videoed to document their individual learning within the program Yes Do you agree to your child being included in photographs/videos at the service taken for publicity and promotion / or for Inclusion in information packs? Yes No Do you celebrate your Child s birthday? Yes No Are there any celebrations/festivals that your family participate in? Please list: DECLARATION As parent(s) and/or guardian/s of (insert child s name) I/we agree to enroll my/our child on the basis of the information provided at the service. I/we declare that the information in this enrolment form is true and correct and undertake to immediately inform the children s service in the event of any change to this information. I/we agree to collect or make arrangements for the collection of my/our child if he/she becomes unwell at the service. I/we are aware of and agree to abide by the Centre and agency policies (a copy is available at the Centre) I/we accept my child s enrolment into this service and agree to pay all fees charged for the provision of care and education for my child/children and understand that a debt collection service will be engaged for non-payment of fees and any associated costs will be added to the debt. I/we consent to the medical treatment of my/our child from a medical practitioner, hospital or ambulance service and acknowledge that i/we are responsible for all associated fees/charges that may apply. I/we agree to all of the actions and conditions in this enrolment form. Signed: Date: Printed Signed: Date: Printed CONFIDENTIALITY AND PRIVACY The Early Childhood Service uses the enrolment form to collect personal information to comply with The Education and Care Services National Regulations and for the purpose of program enrolment (see privacy policy for collection statement and more details). The information provided will be shared with Lentara UnitingCare for operational purposes only (e.g. fee collection, Bad Debt management, program management, statistical information required by Department of Education and Early Childhood Development). The information will not be disclosed to any other party except as required by law.

5 Office Use Only Checklist: Current Contact Details Provided Current Anaphylaxis Medical Management Plan Current Asthma Management Plan Individual Medical Condition Risk Minimisation/Communication Plan Consent to Seek Medical Treatment Emergency Contact Details Medical Condition Details Collaborative Partnerships ie: Enhance Maternal Child Health, Family Support etc. Immunisation details or Letter of Conscientious Objection Court Order Details Early Start Application Sighted (if NO please provide a reason why) Second Year Approval Sighted Copy of Current HCC/PCC/Veteran Gold or White Card/Temp, Refugee/Asylum Seeker Visa Copy of Front Page and Copy of Current Card (list above) and Copy of Checklist, Sent to Lentara UC All sections complete Comments: Name of Educator checking this Enrolment: Signature of Educator checking this Enrolment: Date: