Parent/Guardian Information
Parent/Guardian 1 Parent/Guardian 2
Date of Birth / / Date of Birth / /
Does the child live with this person? Yes No Does the child live with this person? Yes No
Is this person allowed access to child? Yes No Is this person allowed access to child? Yes No
Account Information (person liable for payment of service – may be parent/guardian or Family Service/Agency)
Same as parent/guardian 1 or 2 National Disability Insurance Agency Local Agency (Eg. MacKillop, Glastonbury)
Yes No Yes No Yes (complete below) No
Will this person drop off/collect child? Yes No
Emergency Contact Information
The persons listed below must be notified that they are an emergency contact for the YMCA Vacation Care Service. By listing these persons you are providing authorization that on occasion your child/ren may be dropped off or collect by them. However, please note that the service requires formal notification of any child/ren being collected by anyone other than a parent. Any person who is unknown to staff will need to produce photo ID before collecting your child. All persons authorized to collect a child from the service must be a minimum of 18 years old.
NOTE: ALL RESPONSIBLE CARERS/CASE WORKERS MUST BE LISTED HERE
1. 2.
3. 4.
Child Information
Child 1
Date of Birth / /
Sex Female Male Aboriginal, Torres Strait Island or Australia South Sea Island Origin? Yes No
Medical
Yes No Has Asthma (mild or severe) and carries medication (Attach Action Plan AND Risk Management Plan )
Yes No Has been diagnosed as at risk of Anaphylaxis (Attach Action Plan AND Risk Management Plan )
Yes No Has an allergy or sensitivity (Attach Action Plan AND Risk Management Plan )
Yes No Is fully immunized
Yes No Has special dietary requirements or an important medical condition requires regular medication (detail below)
Important Information
Yes No Has court orders or parenting plans in effect at the time of enrolment (If yes, are these attached Yes No)
Yes No Has had behavioural/emotional/social concerns in previous child service or school setting (If yes please detail below)
Yes No Is there currently a behaviour management plan in place that may assist at our service (If yes, is this attached Yes No)
Yes No Has been diagnosed with an additional need (Eg. ADHD, Autism, Asperger’s, Intellectual Disability (If yes pleasedetail below)
(MUST Complete ISS Forms x3)
Permissions
Yes No Is permitted to have staff provide or reapply sunscreen insect repellent.
Yes No Is permitted to be photographed or filmed for the purpose of curriculum planning (observations and portfolios)
Yes No Is permitted to be photographed or filmed for the purpose of publicity and/or promotions for YMCA Geelong
Yes No Is permitted to attend routine excursions (sometimes impromptu) to nearby Frier Reserve (oval) and YMCA Carpark
Yes No Is permitted to watch G PG rated movies under the supervision and movie pre-approval of management and staff
Yes No Is permitted to participate in face painting
Yes No Is permitted to participate in water play activities which may include excursions to pools/waterparks or land-based
water activities at the YMCA centre. If NO, children will participate in other activities led/supervised by YMCA staff.
Swimming Ability Beginner Intermediate Advanced
Child Information
Child 2
Date of Birth / /
Sex Female Male Aboriginal, Torres Strait Island or Australia South Sea Island Origin? Yes No
Medical
Yes No Has Asthma (mild or severe) and carries medication (Attach Action Plan AND Risk Management Plan )
Yes No Has been diagnosed as at risk of Anaphylaxis (Attach Action Plan AND Risk Management Plan )
Yes No Has an allergy or sensitivity (Attach Action Plan AND Risk Management Plan )
Yes No Is fully immunized
Yes No Has special dietary requirements or an important medical condition requires regular medication (detail below)
Important Information
Yes No Has court orders or parenting plans in effect at the time of enrolment (If yes, are these attached Yes No)
Yes No Has had behavioural/emotional/social concerns in previous child service or school setting (If yes please detail below)
Yes No Is there currently a behaviour management plan in place that may assist at our service (If yes, is this attached Yes No)
Yes No Has been diagnosed with an additional need (Eg. ADHD, Autism, Asperger’s, Intellectual Disability (If yes pleasedetail below)
(MUST Complete ISS Forms x3)
Permissions
Yes No Is permitted to have staff provide or reapply sunscreen insect repellent.
Yes No Is permitted to be photographed or filmed for the purpose of curriculum planning (observations and portfolios)
Yes No Is permitted to be photographed or filmed for the purpose of publicity and/or promotions for YMCA Geelong
Yes No Is permitted to attend routine excursions (sometimes impromptu) to nearby Frier Reserve (oval) and YMCA Carpark
Yes No Is permitted to watch G PG rated movies under the supervision and movie pre-approval of management and staff
Yes No Is permitted to participate in face painting
Yes No Is permitted to participate in water play activities which may include excursions to pools/waterparks or land-based
water activities at the YMCA centre. If NO, children will participate in other activities led/supervised by YMCA staff.
Swimming Ability Beginner Intermediate Advanced
Persons NOT authorized to collect children, please list below Relevant Court Orders/Other attached Yes No
Family Doctor Information
In the event of an accident/illness/trauma, I authorize YMCA Geelong personnel to obtain all necessary medical/ambulance assistance and treatment from a registered medical practitioner, hospital or ambulance service for my child/ren and agree to meet any expenses attached to such treatment.
Yes No
Festivals and Celebrations
Background Information
Has your family has previously attended the YMCA Geelong Vacation Care Program? Yes No
Where did you hear about this program?
Do you have any other children enrolled in a child care service that is not YMCA Vacation Care (eg. Child Care)? If yes, how many?
Reason for accessing YMCA Geelong School Holiday Program (Eg. Work full time, study, single parent, social care, respite, etc.)?
Have you provided your child/ren’s health care record/s for YMCA staff to sight? Yes No
I give permission for the Geelong YMCA Vacation Care Staff to contact my child’s school if necessary to access further information (Eg. behaviour management plans, etc.)
Yes No
I acknowledge that YMCA by law are required to pass on information (eg. names/ages/phone number) to the Department of Education and Early Childhood Development, the Regulatory Authority and, in cases where required, Child FIRST and Child Protection in the event of an incident involving my child/ren. I permit YMCA staff to proceed as required in such instances acknowledging that I will first be informed.
Yes No
Parent/Guardian Declaration
I, the undersigned:
· Confirm that payment will be made for all days booked by due dates, which include any absences due to changed holiday plans, illness, changed care arrangements etc., as per the Registration and Fee policies.
· Understand that CCB is recalculated upon completion of the School Holiday Program and a new invoice will be issued. This may or may not result in amendments to the invoice in comparison to estimates issued prior to program commencement.
· Will ensure that my child/ren have been signed in to the service by 9:00am each day (and earlier where required) as failure to do so may result in children being unable to attend the day’s events.
· Understand that YMCA Geelong has the right to refuse entry or continuation of the program for participants whose personal behavior is deemed unacceptable, unsafe or inappropriate, or if family accounts go unpaid for longer than acceptable.
· Understand that program activities and transport are subject to cancellation, alteration and re-arrangement in the event of unsuitable weather conditions or other factors beyond the control of the YMCA.
· Understand that YMCA Geelong will retain and store registration information on a confidential database (as per YMCA Privacy Policy) and it shall be removed if requested.
· YMCA Geelong does not accept liability for personal injury, property damage or loss sustained by any participant as a result of his/her participation in the School Holiday Program, due to any cause whatsoever unless cause is proven negligent of YMCA Geelong, its directors or employees.
· Have read and agree to abide by the YMCA’s policies & practices outlined in the Parent Handbook.
· Am willing for my child to participate in all experiences offered. I agree that it is my responsibility to familiarize myself with the program and to advise the service in writing if I do not wish for my child to participate in particular activities.
· Understand that this program offers excursions/incursions for which I authorize my child/ren to attend and take part in those selected (consent for individual excursions will be sought when signing children in on the day of said activities however where a parent hasn’t signed permission, staff will sign on their behalf.
· Acknowledge that due to the Children’s Services Regulations requirements there may be times when my child’s full name will be displayed at the service, in records which include but is not limited to: sign in/out forms, communication book, incident/accident reports and action plans. If I have concerns about this issue I will advise the service in writing.
· Have read and understand the cancellation policy.
Medical, Health and Wellbeing
· Agree to inform the service staff of all medical needs and requirements of my child. This includes information of any medical condition, any medication required to be administered and any medication or other substances which should not be provided or administered to my child/ren.
· Understand that the service may require that I collect my child earlier than the designated time due to illness or as a result of an accident at the service that may require further medical attention by the child’s medical practitioner.
· Understand that a doctor’s certificate may be required to allow my child to return to the service.
· Agree to inform program staff if my child contracts any illness which could be detrimental to health of others at the program.
· Will not send my child/ren to the program when they have an infectious or contagious disease, or are unwell.
· Understand and agree to these Terms & Conditions as they are applicable to all future YMCA Vacation Care programs that my child/ren attends.
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