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Manilla Community Pre-SchoolInc. P.O. Box 127, Manilla NSW 2346
24 Carinya Avenue, Manilla
Phone: (02) 6785 1475
Fax: (02) 6785 0039
ENROLMENT FORM
Information as required for Licensing and regulation requirements for NSW Early childhood Services.
Preferred
Child’s Legal Full Name: ______Name: ______
(The name that is on your child’s Birth Certificate)
Other Names Known By: ______Former Names: ______
Residential Address: ______Post Code: ______
Telephone Number: (Home)______(Mobile): ______
Email address: ______
Place of Birth
Date of Birth: _____/_____/_____ Male Female: Town/Country:______
Cultural Identity of Child:______Language spoken at home: ______
Religion of Child:______
Is your child of Aboriginal Background? (Please circle)YesNo
Is your child of Torres Strait Islander Background? YES NO
FAMILY INFORMATION Mother/Guardian Father/Guardian
Full Name: ______
Address and Phone: ______
Number/s if different
from above: ______
Date of Birth:______
Occupation:______
Place of Employment/Study:
______
Work Tel. No.______
Other Children/ Name Date of Birth Male / Female
Related Siblings
______/_____/______
______/_____/______
______/_____/______
______/_____/______
EMERGENCY CONTACT : Although everypossible care will be taken whilst your child is here, staff can in no way be held responsible for any accident that may occur. In the event of an accident or illness requiring emergency medical treatment, every effort will be made to contact parents. If we can’t contact you we need you to nominate two other people. Ideally, the contact people you nominate should be someone who lives in Manilla, has a telephone and can be contacted during the day.
1. Emergency Contact Name: ______
Phone No: (Home)______(Work) ______Mobile)______
Relationship: ______What does the child call this person? ______
2. Emergency Contact Name: ______
Phone No: (Home) ______(Work) ______(Mobile) ______
Relationship: ______What does the child call this person? ______
HEALTH RECORD: It is important to keep this information up-to-date at all times.
Family Doctor: ______Telephone number: ______
Family Dentist: ______Telephone number: ______
Medicare Number: ______Health Fund: ______
(If applicable)
Low Income Health Care Card: (Please circle) Y N
IMMUNISATION: Under the Public Health Amendment Act 2013 all families are required to provide an Immunisation History Statement on enrolment & update as necessary. Your child WILL NOT be enrolled without this document.
Has your child been immunised? YES NO
Does your child have any allergies to food, insect bites, sunscreen etc? YES NO
If yes, please specify, including action to be taken in the event of your child developing any signs or symptoms of an allergic reaction: ______
Does the child have any continuing serious illness?: YES NO If yes, please specify:
______
Asthma?: YES NO ( If YES, please complete the attached Asthma Notification Form).
Disability?: If yes, please specify:
______
Has your child attended a Speech Pathologist, Pediatrician or any other specialist or diagnostic unit?
YES NO If yes, please givedetails:______
Do you have any concerns about your child’s development or behavior? ______
What Primary School will your child attend & in what year? ______
SOCIAL DEVELOPMENT: Has your child previously attended: (Please tick box)
Playgroup Family Day Care Pre-School Babysitter Child Care Centre Other ______
Have there been any changes in the child’s life in the last year? eg. moving house, family break-up,
deaths etc. ______
AUTHORISED PERSONS:-
I give permission for the following people to collect my child from or deliver my child to the Pre-School.
NAME / ADDRESS / PHONEH:
W:
Mob:
H:
W:
Mob:
H:
W:
Mob:
H:
W:
Mob:
Parent’s signature:______Date: ______
If you wish your child to be collected by someone who is not on this list, you must notify the
Pre-School, preferably in writing.
N.B. Staff are unable to release a child into the care of any person other than the parents/guardians or those nominated as Authorised Persons.
ACCESS
Are there any Court Orders relating to the custody of the child? YES NO
If YES, please supply original documents to the Director. YES NO
Documents Supplied
Please complete this section if the child has a parent not residing in the family home.
Title: ____ Surname: ______Given Names: ______
Relationship to Child: ______
Supporting documents eg. of any existing orders must be provided. A photo of the non-custodial parent should be kept on file at the Pre-School for easy identification.
Details of Access: You will need to discuss custody arrangements with the Director. Please specify an “Action Plan” for staff to follow in the event of the non-custodial parent presenting at the Pre-School. You will need to discuss this plan with the Director.
PARENT CONSENT FORM – MEDICAL
In the event of an emergency, illness or accident and the staff being unable to contact me or the person nominated by me, I give permission to Manilla Community Pre-School Inc. to obtain medical, hospital or dental attention for my child. I agree to accept responsibility for expenses incurred, which may include ambulance travel.
Signature: ______Date: ______
PARENT CONSENT FORM – SUNSCREEN
I give permission for sunscreen to be applied to my child.
Signature: ______Date: ______
PARENT CONSENT FORM – INFECTIOUS DISEASE
In the event of my child contracting an infectious disease, I agree to exclude him/her from the Centre for at least the period of time suggested by current guidelines for Early Childhood Centres.
Signature: ______Date: ______
PARENT CONSENT FORM – PUBLICITY
I hereby consent for my child to appear in photographs, videos or television footage which may be displayed by the Pre-School or used for publicity reasons by the Pre-School.
Signature: ______Date: ______
PARENT CONSENT FORM – HEAD LICE CHECK
I give permission for my child’s hair to be checked for head lice as per policy.
Signature: ______Date: ______
PARENT CONSENT FORM – EXCHANGE OF PERSONAL INFORMATION
I give permission for the Pre-School staff to discuss my child’s special interests/skills and needs with the relevant Infants School Teachers as they move off to BIG school and any other early childhood professionals as the need arises including passing on any relevant reports from other professionals. All information is kept confidential.
Signature: ______Date: ______
PARENT CONSENT FORM – PHOTOS ON OUR WEB PAGE
Manilla Preschool has their own webpage ( I consent for my child to appear on this page by way of photos, videos and stories.
PARENT CONTRACT: I agree to pay my fees by the due date. If I am unable to do this I will contact the Director or the Fees Officer to make alternative arrangements prior to that date. I am aware that my child’s enrolment at the Pre-School will be revoked if fees are not paid.
I agree to drop off and collect my child within Pre-School hours – 9.00am to 12 noon (Monday) and 8.00am to 3.30pm (Tuesday to Friday). I understand that I will be charged a late fee beyond 3:30p.m according to fee policy.
I agree to abide by the policies set by the Manilla Community Pre-School Management Committee. A folder containing these policies is kept in the Pre-School foyer and the Committee recommends that all families read the Policy Folder.
I understand that membership of the association is a pre-requisite of my child’s enrolment.
Signature: ______Date: ______
(Mother/Guardian)
Signature:______Date: ______
(Father/Guardian)
Manilla Community Pre-School Inc P.O. Box 127, Manilla NSW 2346
24 Carinya Avenue, Manilla
Phone: (02) 6785 1475
Fax: (02) 6785 0039
As a requirement of Department of Community Services subsidy forms and proof of income need to be provided each year.
A $40 non-refundable fund raising levy per year ($10 per term) per family is charged.
Please fill out form below and return with enrolment form. Those parents required to be on a fee contract will sign this on their first day at Preschool or their child will not be permitted to enroll.
****************************************************
Please choose from the table below how you will be paying your fees for this term and tick the appropriate box:
WeeklyFortnightly
MonthlyIn Full
Childs name: ______
Parent’s name: ______
Signed:______Date: ______
**********************************************************
Thank you for your cooperation in this matter
Yours faithfully
Manilla Preschool Management Committee
APPENDIX 1. (RULE 3(1).)
APPLICATION FOR MEMBERSHIP OF ASSOCIATION
MANILLA COMMUNITY PRE-SCHOOL INCORPORATED
(Incorporated under the Associations Incorporation Act,1984)
I, ______
(Full name of applicant)
of ______
(Address)
______hereby apply to become a member of the
(Occupation)
abovenamed incorporated association. In the event of my admission as a member, I agree to be bound by the rules of the association for the time being in force.
______
(Signature of applicant)
______
(Date)
* * * * * * *
I, ______a member of the association, nominate
(Full name)
the applicantfor membership of the association.
______
(Signature of proposer)
______
(Date)
* * * * * * *
I, ______a member of the association, second
(Full name)
the nomination of the applicant for membership of the association.
______
(Signature of seconder)
______
(Date)
NOTE: Each member is required to pay a membership fee of $2.00. This entitles the member to participate in the Parent Management Committee and, if eligible, to vote at Committee Meetings. Whilst both parents may attend Meetings only one vote will be able to be cast. However, in the event that both parents wish to be actively involved in the Management Committee and both would like to hold voting rights, then each parent will need to become a member of the Association and two membership fees will need to be paid.
CHILDREN’S SERVICES ECONOMIC SUBSIDY APPLICATION FORM
Community Services provides funding for a subsidy in respect of low income parents to assist them to meet the cost of care in a children’s service.
This application form allows the Child Care Centre/Pre-School/Kindergarten to assess your eligibility for this subsidy.
Eligibility for this subsidy is dependent upon completion of this application form.
Parent’s name: ______Spouse’s name: ______
Address: ______Address: ______
______
Phone: (home) ______Phone: (home) ______
(work) ______(work) ______
Number of dependent children: ______(A dependent child includes full-time students supported by you, or any child for whom you receive family allowance)
CHILD TO BE ENROLLED
NAMEAGENUMBER OF SESSIONS
1. ______
2. ______
3. ______
GROSS FAMILY INCOME PER WEEK:PARENTSPOUSE/DE FACTO
1. Salary/Wages (b) ______
2. Pension/Benefit/Allowance ______
3. Interest/Dividends______
4. Maintenance payments ______
5. Other Income (d) ______
SUB TOTAL: ______
Less tax: ______
Nett Income: ______(1) ______(2)
NETT TOTAL WEEKLY FAMILY INCOME: (1) + (2) ______(e)
EXPLANATORY NOTES
(a) Include all details for spouse or de facto residing with the responsible parent.
(b) Salary or wages before tax and other deductions.
(c) Do not include income from Family Allowance, Family Income Supplement,
Handicapped Children’s Allowance or payment for children in Foster Care.
(d)Include value of cash and non cash benefits from employment or self employment.
(e) Proof of Income MUST be provided in order to be eligible for fee relief (e.g. letter fromemployer, pay slips etc.)
(f) Self employed parents should base their claim on previous year’s income if necessary.
PARENT’S STATEMENT
- The information given in this application form is true and correct.
- I/we have provided evidence of family income in support of this application.
3. I/we undertake to advise the Centre of any changes to the information in the application
which would affect the level of subsidy provided.
4. I/we are aware that eligibility must be reassessed on a term by term basis and agree to
complete another application when required as part of the reassessment.
SIGNED:______
(parent)(spouse/de facto)
DATE: ______