Apply SPF 30+ Sunscreen to My Child

Apply SPF 30+ Sunscreen to My Child

CHILD'S DETAILS
Family Name / Address
First Name
Date of Birth / Is your child / Aboriginal
Gender (circle) / Male / Female / (circle) / Torres Strait Islander
Sibling/s Name and Age / Cultural Background
Language/s spoken at home
PARENT/GUARDIAN INFORMATION
PARENT/GUARDIAN 1 DETAILS
Family Name / Home address
First Name
Mobile Number
Work Number / Place of employment
Home number / Work Address
Email address
Does the child live with this parent? / Yes / No
PARENT/GUARDIAN 2 DETAILS
Family Name / Home address
First Name
Mobile Number
Work Number / Place of employment
Home number / Work Address
Email address
Does the child live with this parent? / Yes / No
EMERGENCY CONTACT PERSONS FOR CHILD
EMERGENCY CONTACT 1 / EMERGENCY CONTACT 2
Family Name / Family Name
First Name / First Name
Home address / Home address
Mobile Number / Mobile Number
Work Number / Work Number
Home number / Home number
Relationship to child / Relationship to child
☐ Authorised to collect your child / ☐ Authorised to collect your child
☐ Notification in the event of an emergency / ☐ Notification in the event of an emergency
☐ Authorised to consent to medical treatment / ☐ Authorised to consent to medical treatment
☐ Authorisation for administration of medication / ☐ Authorisation for administration of medication
☐ Authorised to authorise an Educator to take the
child outside of the premises / ☐ Authorised to authorise an Educator to take the
child outside of the premises
CHILD'S HEALTH INFORMATION
Child's medical practitioner
Practitioner phone / Practitioner address
Medicare Number / Medicare Expiry
Ambulance Subscriber No. / Yes / No / Membership Number
Ambulance Member No. / Expiry
Private Health Insurance / Yes / No
Provider / Membership Number
Maternal & Child Health Centre / Maternal & Child Health Nurse
Is your child attending, or has previously attended (circle):
Counsellor/Psychologist / Speech Therapy / Occupational Therapy / Dietician
Paediatrician / Other specialist / Please specify:
CHILD'S MEDICAL INFORMATION
Anaphylaxis (Reg. 162)
Has your child been diagnosed as at risk of anaphylaxis? / Yes / No
Does your child have an auto injection device? (e.g. Epipen or Anapen) / Yes / No
Has the anaphylaxis medical management plan been provided to the Occasional Care Service? / Yes / No
Has a risk management plan been completed by the service in consultation with you? / Yes / No
In the case of anaphylaxis you will be provided with a copy of the Occasional Care Service Anaphylaxis management policy. You will be required to provide the service with an individual medical management plan for your child signed by the medical practitioner treating your child.
Health Care Needs
Does your child have any specific healthcare needs including any medical conditions that are relevant to the care and education of your child? (circle) / Yes / No
If yes please provide details of any specific healthcare need/s or medical condition/s. Attach any plan/s or additional pages if necessary:
Allergies
Does your child have any allergies? (circle) / Yes / No
If yes please provide details of allergies and any management plan/s to be followed. Attach any plan/s or additional pages if required:
Dietary Restrictions
Does your child have any dietary restrictions? (circle) / Yes / No
If yes please provide details of any dietary restrictions:
CHILD'S IMMUNISATION STATUS
Has your child been immunised? (circle) / Yes / No
If yes, provide the details by selecting one of the options below:
☐ Attaching a copy of the Child History Statement from the Australian Childhood Immunisation Register; OR
☐ Attaching a copy of the immunisation record printout from Local Government
Children must be immunised to attend child care services in accordance with the:No Jab No Play Child-care enrolment law in Victoria.
COURT ORDERS IN RELATION TO YOUR CHILD
Are there any:
☐ Court Orders, parenting Orders or Parenting Plans relating to the powers, duties, responsibilities or authorities of any person in relation to your child or access to your child?
☐ Other Court Orders relating to your child’s residence or the child’s contact with a parent or other person?
If yes, please bring the original order/s for the educators to sight and attach a copy to this enrolment form; please describe the orders and provide the contact details of any person given powers, duties, responsibilities or authorities:
ADDITIONAL INFORMATION
Please provide information about your child e.g. interests, likes, dislikes, family traditions, home routines, parenting strategies:
Is your child currently attending, or have they previously attended:
Kindergarten / Playgroup / Long Day Care / Family Day Care
Early Intervention Service / Other / If other, specify:
If yes, please provide details:
If applicable, which Kindergarten have you or do you plan to enrol your child
Please provide the details of any local community services you and your child access e.g. Library, Imagination Magic Sessions, Swimming Pool, local parks etc.:
Would you like additional information regarding Council’s Services and/or services available in the community?
If yes, please provide details:
CONSENT
I, ______, have read the terms and conditions enclosed with this enrolment form and consent to and give permission for Moorabool Shire Council’s Occasional Care Staff to (circle):
  • Apply SPF 30+ sunscreen to my child
/ Yes / No
  • Take photos of my child for purposes solely connected to the Occasional Care Program
/ Yes / No
  • Take photos of my child for public display (i.e. local displays, media/advertising)
/ Yes / No
  • Visit Darley Kindergarten program at the Darley Early Years Hub for the purpose of Kindergarten transition
/ Yes / No
  • Enter into the adjoining outdoor play space and children’s rooms within the Darley Early Years Hub
/ Yes / No
Parent/Guardian Name:
Parent/Guardian Signature: / Date:
PERMISSION
I, ______hereby give permission for the Moorabool Shire Council Occasional Care Service to discuss relevant information with Council’s Maternal Child &Health Service and my child’s prospective Kindergarten Service that will assist staff to support my family and my child’s transition to Kindergarten.
Parent/Guardian Name:
Parent/Guardian Signature: / Date:
AUTHORISATION AND DECLARATION
I, ______,
a person with parental responsibility for the child referred to in this enrolment form (Reg.33):
  • Authorise the Approved Provider, Nominated Supervisor, or an educator to seek:

  • Medical treatment for the child from a registered medical practitioner, hospital or ambulance service

  • Transportation of the child by an ambulance service; and

  • Agree that I am responsible for any expenses incurred during a medical emergency in relation to the child;

  • Agree to collect or make arrangements for the collection of the child if he or she becomes unwell;

  • Understand that in an emergency situation or where evacuation is necessary that the child may need to leave the Occasional Care Service under the direction and supervision of the approved provider, nominated supervisor or educator;

  • Have read and understood the Occasional Care Service’s policies, including the ‘Payment of Fees’;

  • Declare that the information in this enrolment form is true and correct and undertake to immediately inform the Occasional Care Service in the event of any change to this information.

Parent/Guardian Name:
Parent/Guardian Signature: / Date:
Signature of person with parental responsibility of the child
OFFICE USE
Date received / /20 / Staff ______/ Consent:
☐ Immunisation Record Copy / ☐ Apply sunscreen
☐ Asthma/Allergy Medical Form required / ☐ Photographs media/advertising
Date Care Commenced / /20 / ☐ Kindergarten Transition Darley Early Years Hub
Permission: ☐ MCH ☐ Kindergarten Service

Please return your completed enrolment form to the Occasional Care service via mail Moorabool Shire Council, Occasional Care Service, PO Box 18 Ballan, Vic, 3342 in person to Darley Early Years Hub, 182 Halletts Way, Darley or via email to attention to Occasional Care Service Team Leader. For all enquires or for assistance to complete the form please call 5366 7100. This Personal Information is held by Moorabool Shire Council in accordance with the Privacy and Data Protection Act 2014.

Occasional Care PERMISSION Form 2018

Our program is plannedto provide children with the opportunity to explore a wide range of experiences and building upon children’s skills, interests and abilities through play.

The Darley Early Years Hub has been designed as a platform for children’s learning, throughout the year we will be visiting the adjoining outdoor play space at the hub and the children’s room located at the front of the building for special occasions and other planned activities during our sessions. The experiences are planned so that the children can explore, seek new challenges and build upon their confidence at the program. Educators will keep you informed of what is planned for each session through our program plan.

We are seeking consent from you, for your child to participate and be accompanied by the Occasional Care Educators within the indoor and outdoor spaces of Darley Early Years Hub.

If you have any questions please talk further with Syeda in person, or by calling 5366 7100, via email .

Consent

I, ______hereby give permission for my child ______to be accompanied by the Occasional Care Educators to the adjoining outdoor play space and within the Darley Early Years Hub.

Name of Parent/Legal Guardian: ______Signature: ______

Relationship to child: ______Date: ______

Occasional Care Enrolment Form 2018 | 1

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