Children’s Services
Enrolment Form for Before and After School Care and Vacation Care
Parent and Guardian Checklist
Please check that you have completed the following:Please check that you have completed the following:
Read and filled in every section of this form.
Obtained Customer Reference Numbers from the Family Assistance Office for
· The child using the service
· The parent who the child is linked to through Family Assistance
A CRN can be obtained by phoning the Family Assistance Office (FAO) on 135 150
Ensure both of these numbers are provided on this enrolment form
To receive the Child Care Benefit (CCB) phone the Family Assistance Office (FAO) on
136 150. Ask FAO if you can be assessed for CCB eligibility
Have you provided a copy of your child’s birth certificate?
Are immunisation records attached for all Children NEW to the service?
http://www.humanservices.gov.au/customer/services/medicare/medicare-online-services
Are all Action Plans attached in regards to medical conditions?
Have you attached a copy of court orders/parenting plans (if applicable)?
Have you signed the Agreements section and the registration form?
Information
LocationsPeninsula Children’s Services
Peninsula Community Centre
93 McMasters Road, Woy Woy NSW 2256
p: 4344 3018 or m: 0414 911 830
e:
Before and After School Care
6:30 am to 9:00 am & 2:30 pm to 6:30 pm
Vacation Care
7:00 am to 6:30 pm during school holidays / Gosford Children’s Services
Gosford Public School
Block E, Faunce St West, Gosford NSW 2250
p: 4339 9426 or m: 0451 371 713
e:
Before and After School Care
6:30 am to 9:00 am & 2:30 pm to 6:30 pm
Vacation Care
7:00 am to 6:30 pm during school holidays
Point Clare Children’s Services
Point Clare Public School
Takari Avenue, Point Clare NSW
m: 0409 787 844
e:
Before and After School Care
6:45 am to 8:45 am & 2:30 pm to 6:30 pm
Staff Ratios / Cost per session
BASC/Vacation Care
· 1:15 incursions (on site)
· 1:15 excursions
· 1:5 water activities / Child care benefit (CCB) is available for BASC and Vacation Care so please contact the site supervisor for a quote per session.
For more information
Please refer to the Children’s Services Family Handbook
Note: Please tick check boxes or, if completing this form in Word on your computer, please double-click on check boxes and then click on “checked”
Payment Options
Payment of full care during the vacation care period is required at time of booking. We accept cash, cheque, bank deposit and EFTPOS. If paying by bank deposit, please see details below:
Peninsula Children’s Services / Before and After School CareBSB: 032-527
Account number: 220065
Account name: Woy Woy Before and After School Care
Vacation Care
BSB: 032-527
Account Number: 220073
Account name: Woy Woy Vacation Care
Gosford Children’s Services / Before and After School Care
BSB: 032-527
Account number: 220102
Account name: Gosford Before and After School Care
Gosford Vacation Care
BSB: 032-527
Account number: 220110
Account name: Gosford Vacation Care
Point Clare Children’s Services / Before and After School Care
BSB: 032-527
Account number: 220081
Account name: Pt Clare Before and After School Care
Note: Please use your child’s name as the reference so we can link it up with our records
All information contained within this document is collected for the operational purposes of Coast Community Connections Children’s Services, and shall be used solely for these purposes. Coast Community Connections protects and manages your personal information as required by the Australian National Privacy Principles, and NSW and Commonwealth Privacy Legislation.
Children’s Services Enrolment Form
All information in this form is CONFIDENTIAL
Location (Please tick which centre your child is attending)Gosford Children’s Services
Before and After School Care
Vacation Care / Peninsula Children’s Services
Before and After School Care
Vacation Care
Point Clare Children’s Services
Before and After School Care / Note: Please tick check boxes or, if completing this form in Word on your computer, please double-click on check boxes and then click on “checked”.
Child 1 / Child 2
Name
Male/Female / Male Female / Male Female
Date of Birth
Age
Country of Birth
Nationality
Aboriginal/Torres Strait Islander / Yes No / Yes No
School attending
*CRN of Child
/ Parent/Guardian 1 / Parent/Guardian 2 /
Name
Address
Home Phone
Mobile Phone
Work Phone
Email address
Occupation
Employer
Country of Birth
Nationality
* DOB of Parent
* CRN of Parent
* Requirements for CCB rebate. If you are claiming your child care fees on your tax you will need a CRN from Centrelink for yourself and child(ren). You must supply your CRN number to obtain the reduced rate.
Child’s Attendance
Please write the child’s name and tick the days your child(ren) will be attending.
Mon / Tues / Wed / Thurs / FriBefore School Care
Child 1:
Child 2:
After School Care
Child 1:
Child 2:
Please tick here if you only require casual care (BASC)
Vacation Care / Please complete booking form
Starting date / //
If there are any changes in circumstances or days that you are requiring care, please notify us in writing to avoid any misunderstandings. It is also important if your child will be not attending on their permanent booked days to ensure we are notified as soon as possible.
Other informationAre there any court orders affecting the custody of your child?
(If yes, please attach a copy for the centre’s records) / Yes No
Court orders/parenting plans:
Court order/parenting plan provided? / Yes No
Does your child attend any other approved care service? / Yes No
If so, for how many hours a week?
Does your child have siblings who attend other approved care services / Yes No
Details:
Languages spoken at home
Please let us know if there are any religious or cultural requirements that need to be observed whilst your child is in our care
How did you hear about our service?
Emergency contacts and people authorised to collect your child
Emergency Contact 1 / Emergency Contact 2Name
Home address
Home Phone
Mobile Phone
Work Phone
Relationship to child
Emergency Contact / Yes No / Yes No
Authorised to Collect / Yes No / Yes No
Children will only be released to guardians or nominated persons over the age of 18 with photo ID as a child protection measure.
Names and dates of birth of siblings
Siblings / Child 1 / Child 2Name
Date of Birth
Medical information
Family Doctor / Family DentistName
Address
Phone
Other information
Child’s Medicare No
Religious or cultural requirements in case of accidents or illness / Yes No
Details:
Health Information
Please note you will need to submit the following documents for medical conditions your child suffers.
Asthma Action Plan is required to be completed by a registered medical practitioner.
Anaphylaxis Action Plan is required to be completed by a registered medical practitioner.
Health Risk Minimisation Plan-should be finalised in consultation with the Nominated Supervisor at the service when your child commences.
Authority to administer medication form- This form authorises the staff to administer the medication as recorded on the action plan.
/ Child 1 / Child 2 /Are your child’s immunisations up to date? / Yes No / Yes No
Please attach a copy of the immunisation record print out from the National Immunisation register
When was your child’s last tetanus injection?
Does your child suffer from any allergies? / Yes No / Yes No
Details
Does your child have special dietary requirements? / Yes No / Yes No
Details:
Does your child suffer from any medical conditions such as asthma, anaphylaxis, epilepsy, diabetes, etc / Yes No / Yes No
If yes, has an action plan been provided to the service by your registered medical practitioner? / Yes No / Yes No
Details:
If answering yes to anaphylaxis – please answer the following questions
Has your child been diagnosed at risk of anaphylaxis? / Yes No / Yes No
Does your child have a auto injection device (eg EpiPen)? / Yes No / Yes No
Has a health risk minimisation plan be completed by the service in consultation with you / Yes No / Yes No
It is a requirement that you provide the service with an individual medical action plan for your child signed by the medical practitioner who is treating your child.
Has the anaphylaxis action plan been provided to the service / Yes No / Yes No
If answering yes to asthma – please answer the following questions
Has your child been diagnosed with asthma? / Yes No / Yes No
Does your child require regular asthma medication? / Yes No / Yes No
Has a health risk minimisation plan be completed by the service in consultation with you / Yes No / Yes No
It is a requirement that you provide the service with an individual medical action plan for your child signed by the medical practitioner who is treating your child.
Additional information
Does your child have a diagnosed disability or disorder / Yes – please complete Appendix A
No / Yes – please complete Appendix A
No
Is your child on any medications? Please provide details / Yes – please complete Appendix B
No / Yes – please complete Appendix B
No
Has your child got a history of any major illness or had an operation? / Yes No / Yes No
Details:
Is there any other health information staff should be aware of? / Yes No / Yes No
Details:
/ Child 1 / Child 2 /
Are there any behaviours significant to your child that staff should be aware of? / Yes No / Yes No
Details:
Is there any other information you would like to share about any special requirements, cultural or religious beliefs that the staff should be aware of? / Yes No / Yes No
Details:
Agreements
Please read carefully and sign the following. Please note that unless specified these authorisations apply to all our services.
Authorisation for Paracetamol:If my child has a temperature higher than 38° Celsius, the centre is authorised to administer the age appropriate amount of paracetamol to my child. Yes No
Signature of Parent/Guardian 1:
Signature of Parent/Guardian 2:
Authorisation for administering the centre’s asthma kit:
If my child has difficulty breathing at the centre, a First Aid qualified staff member is authorised to administer the correct dosage of Asthma medication to my child. Yes No
Signature of Parent/Guardian 1:
Signature of Parent/Guardian 2:
Immediate Medical Attention
If my child is seriously injured or ill while in care at the centre, I understand that every effort will be made to contact parents or emergency contacts. I agree that the nominated supervisor or delegate will seek urgent medical, ambulance or hospital treatment. I give permission for medical treatment for my child from a registered medical practitioner, hospital or ambulance service and will pay any costs incurred. I give permission for transportation of my child by an ambulance service. R. 161 (i) (ii).
Yes No
Signature of Parent/Guardian 1:
Signature of Parent/Guardian 2:
Permission for use of sunscreen and insect repellent
I give permission for the use of sunscreen and insect repellent on my child. Yes No
Signature of Parent/Guardian 1:
Signature of Parent/Guardian 2:
Excursions
My child is authorised to take on routine excursions or outings away from the centre. These outings will be within walking distance of the centre, and will not cross any major roads or involve transportation. For all non-routine excursions (for example, where private and public transport may be used), separate permission will be sought. Yes No
Signature of Parent/Guardian 1:
Signature of Parent/Guardian 2:
I have read and understood all excursions on our current program. I am aware that this may consists of my child/ren walking or catching transportation e.g. car, bus, or ferry. Yes No
Signature of Parent/Guardian 1:
Signature of Parent/Guardian 2:
Travel
My child is authorised to travel by bus, car, ferry or walking as required by the program.
Whilst all possible care will be the taken, Coast Community Connections and its staff will not be held responsible for any illness or accident which may occur as a result of Children’s Services’ activities. Yes No
Signature of Parent/Guardian 1:
Signature of Parent/Guardian 2:
Toys, games etc from home
I will not hold the organisation or its staff responsible for children who choose to bring expensive toys, electronic toys, games and swapping cards, etc
Yes No
Signature of Parent/Guardian 1:
Signature of Parent/Guardian 2:
Permission for view G and PG rated DVDs
I give permission for my child to watch G and PG rated videos/DVDs. Yes No
Signature of Parent/Guardian 1:
Signature of Parent/Guardian 2:
Authorisation for Photographs and Filming
My child is authorised to be filmed or photographed for use in learning displays, documentation of the children’s work and portfolios within the centre Yes No
Signature of Parent/Guardian 1:
Signature of Parent/Guardian 2:
My child is authorised to be filmed or photographed for use on Coast Community Connections website and in centre publications and promotions. Yes No
Signature of Parent/Guardian 1:
Signature of Parent/Guardian 2:
My child is authorised to be filmed or photographed by other parents or visitors
to the centre, including students Yes No
Signature of Parent/Guardian 1:
Signature of Parent/Guardian 2:
Payment of fees
I understand that all fees must remain at least two (2) weeks in advance at all times to ensure my child’s position at the centre. Yes No
Signature of Parent/Guardian 1:
Signature of Parent/Guardian 2:
Acceptances of rules, regulations and requirements
I/we have understood and accept the rules, regulations and requirements pertaining to my child’s enrolment in this form, in the centre Handbook and Policies and Procedures folder. I understand and will abide by all the conditions appearing in this form, in the Handbook or in any documentation, as amended by the centre. I declare that the information given above is accurate and agree to notify the centre immediately, in writing, if there are any changes to the above information
Yes No
Name of Parent/Guardian 1:
Signature:
Date / //
Name of Parent/Guardian 2:
Signature
Date / //
Photograph of your child
Please provide a small photo of your child if this is their first time at Before and After School Care/Vacation Care.