HOLIDAY FUN TIMES DETAILED ENROLMENT FORM

OCTOBER 2012

1. ACCOUNT HOLDER’SDETAILS

Full Name:

/ DOB:
Sex: / Male / Female / County of Birth:
Relationship to Child/ren: / Languages:
Family CRN:
Home Address: / Suburb: / P/C
Home Phone: / Mobile Phone:
Family Email:
Place of Work: / Full Time / Part Time / Phone:
Work Address: / Suburb: / P/C
Can Collect: / YES / NO / Emergency Contact: / YES / NO
2. MAIN ADDITIONAL CONTACT’S DETAILS (Other than account holder)

Full Name:

/ DOB:
Sex: / Male / Female / County of Birth:
Relationship to Child/ren: / Languages:
Home Address: / Suburb: / P/C
Home Phone: / Mobile Phone:
Place of Work: / Phone:
Work Address: / Suburb: / P/C
Can Collect: / Yes / No / Emergency Contact: / Yes / No
3. ADDITIONAL CONTACT’S DETAILS (Who may be required to collect children)
Full Name: / DOB:
Relationship to Child/ren: / County of Birth:
Home Address: / Suburb: / P/C
Daytime Phone: / Mobile Phone:
Can Collect: / Yes / No / Emergency Contact: / Yes / No

CHILDREN’S DETAILS:

1. / First Name: / Surname of child:
Child CRN: / % / Gender: / Male / Female
Date of birth: / Age: / Country of Birth:
School: / Year commenced: / Grade at School:
1st Language: / 2nd Language: / Swimming Level:
Fully Immunised: / YES / NO / Photo’s permitted: / YES / NO
2. / First Name: / Surname of child:
Child CRN : / % / Gender: / Male / Female
Date of birth: / Age: / Country of Birth:
School: / Year commenced: / Grade at School:
1st Language: / 2nd Language: / Swimming Level:
Fully Immunised: / YES / NO / Photo’s permitted: / YES / NO
3. / First Name: / Surname of child:
Child CRN: / % / Gender: / Male / Female
Date of birth: / Age: / Country of Birth:
School: / Year commenced: / Grade at School:
1st Language: / 2nd Language: / Swimming Level:
Fully Immunised: / YES / NO / Photo’s permitted: / YES / NO
4. / First Name: / Surname of child:
Child CRN: / % / Gender: / Male / Female
Date of birth: / Age: / Country of Birth:
School: / Year commenced: / Grade at School:
1st Language: / 2nd Language: / Swimming Level:
Fully Immunised: / YES / NO / Photo’s permitted: / YES / NO

Are there any Family Court orders affecting custody of, or access to the child/ren? Yes / No

Please provide details and a copy of the court order:

MEDICAL INFORMATION

Is there any medical or physical condition from which your child/children suffer that needs to be brought to the attention of the Coordinator/Supervisor. For example – special dietary needs; allergies; medical conditions such as ADD, Epilepsy, Asthma, etc.

PLEASE GIVE DETAILS
PROBLEM:
TREATMENT:
Preferred Doctor: / Surgery :
Address: / Suburb:
Post Code: / Phone: / Fully Immunisation: / Yes / No
Medicare Number: / Ambulance Number:
Insurance Fund: / Insurance Number:

ACCIDENTS AND ILLNESS

We regret we are unable to care for sick children or children with contagious illnesses. Prescribed medicines will only be administered to children by Supervisors under written parent authorization and confirmation of prescription details of child/ren on medication by doctor specifying the name, time, quantity and manner of administration. Written authority is also required for child/ren self-administering and all medication must be given to the Supervisor on arrival to be kept in a locked cupboard. In the event of any accident or illness, I authorize the obtaining on my behalf of such medical or hospital treatment as my child/children may require, and agree to meet any expenses attached there to. In the case of emergency I agree for my child to be transported by private vehicle/ambulance. I/we agree to pay expense incurred for medical treatment and transport.

Signature of Parent or Guardian: / Date:

Selection of Attendance Days

Please follow instructions carefully and give some thought to your requirements for enrolment before filling in the table below.

  1. In the column marked ‘number of days required’ please indicate the number of days you require care for each child. Do this for each week
  1. Place a tick in the boxes of the days you hope to book and a cross in any days you definitely don’t want. You must then number all boxes except those crossed, in order of preference, 1 being your 1st preference 2 your 2nd preference etc. Please note the more options you give us the greater chance you have of being allocated your full number of days requested. See example

In the example below I am requesting 1 day for the first week, Thursday being my preferred day with Friday then Tuesday as possible alternatives. I do not want care for Wednesday.

For the second week I am requesting 2 days. Monday and Wednesday being my preferred days, with Tuesday as a possible alternative. I do not want care on Thursday.

Example only / Days required / Mon 14/4 / Tue 15/4 / Wed 16/4 / Thurs 17/4 / Fri 18/4
Child Name / 1 / Public Holiday / 3 / X / √ 1 / 2
Days required / Mon21/4 / Tue22/4 / Wed23/4 / Thurs24/4 / Fri25/4
Child Name / 2 / √ 1 / 3 / √ 2 / X / X

Fill in your enrolment preferences in the chart below

WEEK 1 / Days required / Mon 1/10 / Tues 2/10 / Wed 3/10 / Thurs 4/10 / Fri 5/10
1 CHILD NAME / Closed for Public Holiday
2 CHILDNAME
3 CHILD NAME
4 CHILD NAME
WEEK 2 / Days required / Mon 8/10 / Tues 09/10 / Wed 10/10 / Thur 11/10 / Fri 12/10
1 CHILD NAME
2 CHILDNAME
3 CHILD NAME
4 CHILD NAME

PARENT/GUARDIAN AGREEMENT

  1. I am aware that it is my responsibility to ensure my child/ren is signed in and out every day they attend the centre. I understand that this is a requirement of the FAO and failure to do so may result in full fees being charged.
  1. I understand that I am required to give written permission each day for whom will pick up my child/ren other than myself and photo identification would be required.
  1. I am aware that if I am late in collecting my child/ren there will be a late fee of $5.00 per every five minutes that I will have to pay.
  1. I am aware that all fees are to be paid prior to the commencement of the program and that there are no refunds due to non-attendance days or sickness. I understand that childcare benefit is available but until City of Gosnells receives written notification from Centrelink, I will be responsible for the entire fee. Childcare Benefit is my responsibility to maintain and the centre will only apply the Benefit from the notified date from Centrelink.
  1. I give permission for my child/ren to participate in all activities offered in the vacation care program.
  1. I agree to give permission for my child/ren to travel on public transport, City of Gosnells vehicles or private charter bus on excursions during the vacation care program.
  1. I agree to give permission for my child/ren to walk in groups with centre staff for an activity or during an excursion.
  1. I agree it is my responsibility to familiarise myself with the programat the start of each day.
  1. I agree to comply with all Government requirements in relation to the Centre and its service.
  1. I am aware that the policy of NO HAT NO PLAY applies to the program and if I do not supply a hat for my child/ren daily then they will be required to stay indoors.
  1. I understand that the program may change without notice due to change in weather or unforeseen circumstances.
  1. The City of Gosnells reserves the right to terminate this Agreement when, in its discretion, it considers that to do so would be in the interest of the program. It agrees to give the parent reasonable notice of its intention to exercise this right and will refund any payments in credit.
  1. I am happy for the staff to take photos of my child participating in Holiday Funtimes and understand that these photos will only be used for the purpose of promoting the City of Gosnells programs.
  1. I am aware that the City of Gosnellsis not responsible for any personal belongings that children bring into the centre, including electronic games. Mobile phones are not permitted.
  1. I give permission for the City of Gosnells Holiday Funtimes staff to apply sunscreen to my child and zinc on excursions as required complying with the sun safe policy.

I HAVE READ AND FULLY UNDERSTAND THE ABOVE CONDITIONS OF THIS AGREEMENT AND AGREE TO ABIDE BY THEM. I ALSO AGREE THAT ALL INFORMATION GIVEN IN THIS ENROLMENT FORM IS TRUE AND CORRECT.

Parent Signature ______Date______

Witness Signature ______Date______