COUNTRY CRECHE CHILDCARE CENTRE & PRE-SCHOOL, MATANGI

608 Marychurch Road, RD4, Hamilton

Phone: (07) 829 5635

Fax: (07) 829 5639

WEBSITE: www.countrycreche.co.nz

EMAIL:

______

COUNTRY CRECHE ENROLMENT FORM Acc. Number ______(Office Use)

......

Child’s official surname or family name:

Child’s official given name:

Child’s official other names / middle names:

please separate names with a comma):

Name your child is known by / preferred name:

Surname / family name: Given name:

Child’s date of birth: / / / Male / Female

Child’s primary residential address:

Post Code:

Child’s ethnic origin/s: Iwi your child belongs to:

Language/s spoken at home:

Copy of official identity verification document* collected by staff:
q New Zealand birth certificate
q New Zealand passport
q Other / q Foreign birth certificate
q Foreign passport
Staff initials:

Privacy Statement:

We are collecting personal information on this enrolment form for the purposes of providing early childhood education for your child.

We will use and disclose your child’s information only in accordance with the Privacy Act 1993. Under that Act you have the right to access and request correction of any personal information we hold about you or your child.

Details about your child’s identity will be shared with the Ministry of Education so that it can allocate a national student number for your child. This unique identifier will be used for research, statistics, funding, and the measurement of educational outcomes.

You can find more information about national student numbers at: www.minedu.govt.nz/parents

Account Name Home Phone

Parent/Guardian Work/Mobile

(Relationship to child)

Parent/Guardian Work/Mobile

(Relationship to child)

Emergency Contact Phone Number

Email invoice Yes/No Email newsletter Yes/No

Email address

People Authorised To Collect Child

Special Custody/Access Conditions: Yes/No (if yes please provide relevant documentation)

Doctor/Location Doctor’s Phone

Medical Information eg Allergies

Immunisations Current: Yes/No

Please provide a copy of immunisation records or inform us if your child is not immunised.

We are obliged by Government Regulations to sight the Immunisation Certificate

Special dietary needs: Yes/No if yes please give details

Cultural or Religious Considerations: Yes/No if yes please give details

I give permission for the centre to take photographs: Yes/No and do observations Yes/No of my child – to use for centre purposes eg profile books, programme planning, newsletters, wall displays and website/facebook information.

I give permission for my child to be taken on short excursions near the centre grounds:

Yes/No

The maximum ratio will be 1adult to 5 children (under 2’s) & 1 adult to 10 children (over 2’s & pre-school) Families will be notified and written consent will be required for all outings/excursions outside the centre

I give permission to apply:

Arnica / Y / N / Savlon / Y / N / Aloevera gel / Y / N
Stingoes
(to treat stings/bites) / Y / N / Sunblock / Y / N / Insect repellent / Y / N

I give permission in the event of an emergency for the centre to take necessary action and treat my child (doctors, ambulance) on the understanding I will meet any costs that are incurred: Yes/No

BOOKING / AM / PM / /
MONDAY / / / /
TUESDAY / / / /
WEDNESDAY / / / /
THURSDAY / / / /
FRIDAY / / / /

*All children receiving funding for the 20 Hours ECE (3-5years) are expected to attend a minimum of 2 days a week for 6.5 hours per day.

Bond: 2 weeks of your child’s booked hours is required to be paid 2 weeks in advance. This bond will ensure your child’s booking is secured. The bond is non refundable in the event that your child does not end up attending the centre. The bond will be refunded at the time your child leaves the centre, less any outstanding fees.

ENROLMENT DATE: / /

START DATE: / /

END DATE: / /

I hereby state that this child is not enrolled at any other Government Funded Institution for the same hours as listed above. I understand that the centre management reserve the right to terminate a child’s enrolment in the event of lack of payment or if other ongoing issues arise that cannot be resolved. I am aware that should a debt collection agency be used to recover any unpaid fees, additional collection costs will be added to the outstanding balance.

Parent/Guardian Signature Date

Further information:

Bond Paid: Yes/No Date Paid: Amount Paid:

20 Hours ECE Details:

Child’s Name:

Is your child receiving 20 Hours ECE for up to 6 hours per day, maximum of 20 hours per week at this service? Yes No

If yes, have you attested on the enrolment or booking form?

Yes No

Is your child receiving 20 Hours ECE at any other services?

Yes No

I have agreed to pay the hourly fee of $7.00

Parent/Guardian Signature Date