APPLICATION FOR ENROLMENT

95 Glenora Street, Wynnum Qld 4178

Phone: (07) 3396 8800

ABN: 41095691384

Email address:

The Montessori JourneyEnrolment Form

Phone: 07 3396 8800

Child’s name ______Second name ______Surname______

Address ______

Telephone ______ Nationality______

Sex M / F ______DOB ______Country of Birth ______

Primary language spoken at home ______

Does your child speak English? Yes / No

Name of your child’s present Kindy ______

(This may be used as a reference)

Mother/ Female Guardian

Title ____ Name ______Surname______

Home phone______Work phone______Mobile______

Address______Email______

Nationality______Occupation______

Place of employment______

Father/Male Guardian

Title ____ Name ______Surname______

Home phone______Work phone______Mobile______

Address______Email______

Nationality______Occupation______

Place of employment______

(The person who will be claiming the Childcare Benefit rebate only needs to put their DOB)

Culture/ Religion

Is there anything we should know about your child’s culture? Yes/No

Is there anything we should know about your child’s religion? Yes/ No

If so, please give detail______

______

Would you like to share any skills, talents, interesting aspects to your family or working lives to enrich the experiences of the centre children______

______

Application for position

Days you wish your child to attend (please circle) Mon Tue Wed Thur Fri

Hours of care ______1st attendance date _____Age on 1st attendance_____

Has your child been in childcare before? Yes / No If yes, please give details ie. Which centre?______

______

Employment Status: (please circle one number only)

(1) Sole parent work related (2) Sole parent work not work related

(3) Both parents work related (4) Two parents – one or both not work

related.

Work related includes the following – please circle the most appropriate explanation.

  • Unemployed and seeking work
  • Studying/Training
  • Employed full/part-time

______

Child Care Management System information needed to claim your Child Care Benefit rebate:

Child’s name______Parent/Guardianname:______

DOB:______DOB:______

CRN:______CRN:______

Does your child use another Service? Yes / No (If yes, this could effect your eligible hours)Number of children attending this or another centre ______

(If this information is incorrect, you may be liable to pay back the money at the end of the year)

Doctors Name______Telephone______

Address______Medicare Number______

Private health insurance Y/N Number.______Name______

Child’s Position in family (circle) 1 2 3 4 5 6

Names and ages of Brothers and Sisters:______

Is the child adopted Yes / No If so does the child know Yes / No

Medical History

Has your child received all immunisations for his /her age? (Please provide a Vaccination Schedule for reference)Yes / No If you are a conscientious objector, please give details eg. Homeopathic. etc ______

______

Does your child have any allergies? e.g. grass, food, sunscreen etc. Yes / No
If yes, give details and is any medication required? ______

Does your child have any hearing or visual problems? Yes / No
If yes, please describe______

______

Does your child have any physical or emotional problems, language or speech difficulties, developmental delays, special needs or challenging behaviours that we should be aware of? Yes / No If yes, please give details ______

______

______

Are there any family related illnesses or problems of which we should be aware of (eg. Dyslexia, Epilepsy Asthma , convulsions etc ) Yes / No

If yes please give details ______

______

Does your child have any particular dietary requirements/ preferences? Yes/No

______

Medication treatment information

Asthma/respiratory problems Yes / No Allergies Yes / No

Heart problems /blood pressure Yes / No Phobias Yes / No

Resent illnessYes / No Epilepsy Yes / No

OperationsYes / No Travel sickness Yes / No

Drug reactions (eg. Penicillin)Yes / No Drugs required Yes / No

I have read and understood the Parent Hand Book supplied by The Montessori Journey and agree to its terms and conditions.

Signed______Date ______

Permission to collect your child/ren or act as an emergency contact:

Please include everyone who will be picking up your child, including yourself.

Name______

Address______

Telephone ______Relationship to child______

Name______

Address______

Telephone ______Relationship to child______

Name______

Address______

Telephone ______Relationship to child______

Name______

Address______

Telephone ______Relationship to child______

I/We hereby give permission for the above persons to collect my child when

I/We are unavailable.

Mother/Guardian ______Father/Guardian______

(Only one parent’s consent is needed for the authorisation to pick up the child)

Custody Information

Are there any court orders affecting the child Yes /No If yes, please provide documents. If separated or divorced who has custody of the child?______

Any other comments______

Permission form

I give permission for staff to contact my child’s last kindy/childcare and use them as a reference for my child. Name of Centre?______

Telephone______Signed______Date______

I give permission for the staff to apply sunscreen on my child before outside play. (Parents tosupply a hat and a named sunscreen if you would prefer your child use their own sunscreen)

Signed______Date ______

I give permission for my child______to be observed. These observations would mainly be by students or people interested in how Montessori works.

Signed______Date ______

I give permission for my direct debiting amount to be altered by administration staff only for CCB (Centrelink child percentage) changes, late fees, extra days taken and arrears retrieval (for any other reasons the parent will be notified).

Signed______Date ______

I hereby consent for my child’s photograph to be taken for purposes within the centre. Any other photographs parents will be notified first.

Signed______Date ______

I authorise the staff or instructors to obtain medical assistance, should an accident occur. I agree to pay all medical expenses incurred on behalf of the my child. I further authorise qualified practitioners to administer anaesthetic if such eventuality arises every effort will be made to contact the parents before such treatment is sought.

Signed: Mother ______Date ______

Father ______Date ______

(only one signature necessary)

Thank You

Please return this form, together with the $10 non-refundable application fee, to the Centre via mail or in person. Your child’s name will be placed on our Waiting List and you will be contacted as soon as there is a vacancy available. Should you wish to discuss any aspect of this application, please call the Director directly on (07) 3396 8800.

The Montessori Journey Enrolment Form 1 of 9 pages

THE MONTESSORI JOURNEY VACCINATION RECORD

CHILDS NAME AND SURNAME ______DATE OF ENROLMENT______

AGE / DISEASE / VACCINATION / DATE GIVEN / DOCUMENT USED FOR VERIFICATION / SIGHTED BY: PLEASE PRINT NAME / SIGNATURE / TODAYS DATE
Birth / Hepatitis B / Hep B
2 months / Diphtheria, Tetanus, & Pertussis. Hib, Polio Pneumococcal
Haemophilus Influenzae
type B
Polio / DTPa –Hep B
Pedvax
OPV
4 months / Diphtheria, Tetanus, & Pertussis,
Hepatitis B
Hib
Polio
Pneumococcal
Polio / DTPa – Hep B
OPV
6 months / Diphtheria, Tetanus, & Pertussis,
Hepatitis B– or at 12 months
Hib
Pneumococcal
Polio / DTPa –Hep B
OPV
12 Months / Measles, Mumps, Rubella
Hepatitis B – or at 6 months
Hib
Meningooccal C / MMR
4-5 Years or School Entry / Diphtheria, Tetanus, & Pertussis
Measles, Mumps, Rubella
Polio / DTPa
MMR
OPV

I have chosen not to have my child vaccinated and understand that my child will be excluded for the prescribed period during any outbreak of a vaccine-preventable disease within this Centre

Parent Signature______Date______Developed from the Immunise Australia Program.

If you are a conscientious objector, or other please fill in comments: ______

The Montessori Journey Enrolment Form 1 of 9 pages