Bridgewater PCYCOSHC/Vacation Care Enrolment Form

Bridgewater PCYCOSHC/Vacation Care Enrolment Form

Childs Full Name:
Address: / Child lives with:
DOB: / Sex:
Home Phone: / Language Spoken (ie English):
School Attending:
Grade: / Class Teachers Name:
Mother/Guardian Name
Address:
Home Phone: / Mobile Phone
Place of Employment:
Work Phone:
Father/Guardian Name
Address:
Home Phone: / Mobile Phone
Place of Employment:
Work Phone:
Emergency Contact Name
Address:
Home Phone: / Mobile Phone
Relationship to child:

Does your child have any special requirements that the Centre should be aware of relating to culture, religion, or special needs:

Health & Medical History:

Does your child suffer from any allergies, health or medical conditions? If yes, please state or if No write NIL

If yes please state reaction/treatment required:

Medicare Number:______

Child’s Doctor:______Phone Number:

Surgery Address: ______

Child’s Dentist: ______Phone Number:

Surgery Address:______

When did your child have his/her last tetanus injection?___

Immunisation

Has this child been fully immunised?YESNO

Please provide bring your Health Centre Book or Certificate from Australian Childhood Immunisation Record showing your child’s immunisation status to our Co-ordinator who will photocopy it for our records. Should you not have the above information you will need to provide the Centre with a Statutory Declaration stating that your child has been fully immunised. Please arrange to see the Club Superintendent who can sign the Statutory Declaration.

Head Lice

I give /do not give permission for my child to be inspected by Child Care staff for head lice. If live lice or eggs are found I accept that my child will be excluded from the Program until treatment has commenced.

Consent

If emergency medical care is required by my child I hereby authorise the staff to act on my behalf to seek medical attention and agree to meet any expenses incurred.

Signed:

Name:______Date:

Court Orders relating to this child

Are there any court orders relating to the powers and responsibilities of the parents in relation to the child or access to the child?

NO(go to next section of form)YES (please complete the following)

1. Bring the original court order/s to the Club Superintendent and copy for attachment to this enrolment form
2. If these orders change please bring the updated orders to the Club Superintendent for updating

Requested Days & Fee Payments

This forms only needs to complete once to include all siblings

Child’s Surname / Child’s Name / DOB / School

Please circleAfter School CareVacation Care

Days & type of carePermanentCasualStart Date

Name/s of Person/s who will be picking up the Child/ren:
Vacation Care / Monday / Tuesday / Wednesday / Thursday / Friday

Name and address of person responsible for payment of fees

Name:

Address:

I accept responsibility for the payment of accounts relating the care for the above mentioned child/ren.

I give/do not give permission for my child/ren to be taken on walks and or excursions outside the premises of the Bridgewater PCYC accompanied by regulatory staff ratios.

I give/do not give permission for my child/ren to be transported in the Bridgewater PCYC bus and staff cars if necessary.

Signed:

Name:Date: