Child’s Surname: / First Names (in full): / Preferred First Name:
Gender: (circle one)
Male Female / Date of Birth: / Language Spoken a Home:
Ethnicity: (statistical) With which of the following ethnic group(s) do you identify (please circle)
Note: on acceptance of enrolment, you will be given an opportunity to advise us on cultural matters which may assist us
Enrolment Details
Enrolment Details: (please complete/tick as appropriate):
Permanent Casual Interested in Holiday Programme
Please tick the days you would like to enrol your child and provide times of care if known (we are open the five week days from 3.00 p.m. to 5.30 p.m.
People Authorised to Collect Your Child: / People NOT Authorised to Collect Your Child:
School Attended by your Child: (please list the name of the school your child attends so that they can be used as a point of contact if your child is unexpectedly absent) / Travel to After School Care: (please circle at least one)
Walk Bicycle Car School Bus
Health Details
Details of Child’s Doctor:
Name:
Contact Phone:
Address: / Child Health Matters: Does your child have any particular health needs we should be aware of? (e.g. allergies, food requirements, asthma, medical conditions etc)
Parent/Caregiver Details
Caregiver 1 Details: (enrolling parent / caregiver)
Name:
Relationship to student: (include guardianship status if applicable) / Caregiver 2 Details:
Name:
Relationship to student: (include guardianship status if applicable)
Contact Details:
Address:
Home Phone:
Work Phone:
Mobile Phone:
e-mail: / Contact Details:
Address:
Home Phone:
Work Phone:
Mobile Phone:
e-mail:
Family Details
Brothers/Sisters: (names - optional)
Custody/access Arrangements:
Custody/access arrangements about which we should be aware of?
Additional Information:
Is there anything else we should know about in order to take good care of your child? (e.g. special needs, behavioural issues etc) / Emergency Contact Person 1:
(different to parent/caregiver as listed above)
Name:
Relationship to Child:
Address:
Home Phone:
Work Phone:
Cell Phone:
Emergency Contact Person 2:
(different to parent/caregiver as listed above)
Name:
Relationship to Child:
Address:
Home Phone:
Work Phone:
Cell Phone:
General
Publication of Child’s Photo/Work: From time to time we take photographs of children to record activities. We may use some of these photographs on the Milton Primary School website to share what happens at Koru Time. It is the school’s policy that any photos/work for publication are positive depictions of the children. Do you give permission for your child’s photo and/or work being used for such purposes? /
Yes /
No
Fee Payment: For children attending regularly, please confirm that a regular automatic payment or internet payment has been set up. (Please note that for children attending casually, payment is required on the day of attendance). /
Yes /
No
WINZ Subsidy: Do you have or are you seeking a WINZ subsidy? /
Yes /
No
Parent Contract
Please sign this contract to complete enrolment. If you have any questions about the programme or wish to see a copy of the programme policies prior to signing, please do not hesitate to ask a member of staff.
I/we agree and acknowledge:
· I have read and understand the enrolment information
· I understand that it is my responsibility to notify the supervisor if my child will not attend on a day that they are booked in for but I am still required to pay for the booking unless a prior arrangement has been made with the supervisor
· Koru Time will not take responsibility for any child(ren) who leaves the school grounds without permission
· The supervisor has my permission to arrange any necessary urgent medical treatment at my cost
· I will notify the supervisor of any changes to enrolment information in a timely fashion.
· I agree to pay fees as stipulated in the fees policy.
· I have read the information provided to me about the programme and discussed the expectations of the programme with my child(ren).
All care will be taken to provide supervision of children attending the programme in accordance with programme policies and procedures.
Name of Parent/Guardian: ……………………...………………………………….
Parent/Guardian Signature: ……………………………………………………….
Date: …………………………………………………………………………………..
Privacy Act 1993: The information that you have supplied is necessary for the safe and effective operation of the OSCAR programme. All personal information requested will be destroyed at the completion of your child’s time in the programme. You are welcome to review information pertaining to your child’s enrolment at any time.
Additional Information