(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: 3 Year Old Kindergarten
Group Name: 4 Year Old Kindergarten
Child Care: Age Group: 0-1 1-2 2-3 3-5
Information about your Child Date Of Birth:
Family Name: Given Name: Preferred Name: Residential Address: Suburb: Postcode:
Who does the child live with?
(Please circle) Mother only Father only Both Parents Guardian 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? Aboriginal / Torres Strait / Both If yes, Please Circle
Does your Child/Family hold a:
(Please provide a copy of the document) Reference Number: Expiry Date: Sighted:
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
Parent and Guardian Information:
(
A person who is authorised to authorise an educator to take child outside the education and care service premises) Parent/Guardian CRN: Parent/Guardian CRN: Parent/Guardian Full Name: Parent/Guardian Full Name: Parent/Guardian Date of Birth (Childcare only ) Parent/Guardian Date of Birth (Childcare only ) AddressIf different from Child
Address
If different from Child
Occupation: Occupation:
Country of birth Country of birth:
Telephone/s: Home: _______________________________________ Work: ________________________________________ Mobile: _______________________________________ Email: ________________________________________ Telephone/s: Home: _______________________________________ Work: ________________________________________ Mobile: _______________________________________ Email: ________________________________________
How do you prefer to receive information/correspondence? Please circle: Email 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? Yes / No
Yes / No Yes / No Yes / No Yes / No
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: Contact name:
Address: Address:
Business phone: Business phone:
Home Phone: Home Phone:
Mobile: Mobile:
Relationship to child: Relationship to child:
Child’s Doctor/Medical Centre:
Address:
Telephone: Medicare Number:
Ambulance Cover: Yes / No Private Health Details:
Has your child been hospitalised? If so, for what condition?
Does your child require any additional support to participate in the program? Yes No
If so, please list:
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.
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 Name: Contact Number:
Agency:
Contact Name: 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.
Name: Name:
Address: Address:
Phone No: Phone No:
Relationship to child: Relationship to child:
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 Go to the next section
Yes 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
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 Name:__________________________________________________________________________
Signed:__________________________________________________________ Date: ______________________
Printed Name: _________________________________________________________________________
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.
Office Use Only Checklist:
Current Contact Details Provided Yes No N/A
Current Anaphylaxis Medical Management Plan Yes No N/A
Current Asthma Management Plan Yes No N/A
Individual Medical Condition Risk Minimisation/Communication Plan Yes No N/A
Consent to Seek Medical Treatment Yes No N/A
Emergency Contact Details Yes No N/A
Medical Condition Details Yes No N/A
Collaborative Partnerships ie: Enhance Maternal Child Health, Family Support etc. Yes No N/A
Immunisation details or Letter of Conscientious Objection Yes No N/A
Court Order Details Yes No N/A
Early Start Application Sighted (if “NO” please provide a reason why) Yes No N/A
Second Year Approval Sighted Yes No N/A
Copy of Current HCC/PCC/Veteran Gold or White Card/Temp, Refugee/Asylum Seeker Visa Yes No N/A
Copy of Front Page and Copy of Current Card (list above) and Copy of Checklist, Sent to Lentara UC Yes No N/A
All sections complete Yes No N/A
Comments:
Name of Educator checking this Enrolment: Signature of Educator checking this Enrolment: Date:
