ENROLMENT FORM 2017

PART 1 – CHILD/FAMILY INFORMATION

Child’s Full Name: ......  Male  FemaleDate of Birth: ......

Home Address: ...... Age on Commencement: ......

...... Postcode: ...... Child’s CRN: ......

Indigenous Status:Aboriginal NOT Torres Strait Islander Torres Strait Island NOT Aboriginal 

(please tick)Aboriginal AND Torres Strait Islander NOT Aboriginal nor Torres Strait Islander 

DAYS OF ATTENDANCE(please circle):Monday Tuesday Wednesday Thursday Friday

Guardian No.1: ......
Relationship to Child: ......
Guardian No.1 Date of Birth: ......
Guardian No.1 CRN: ......
Address:......
......
Telephone (H):......
Mobile: ......
Workplace: ......
Telephone (W): ......
Email: ......
Medicare No.:...... / Guardian No.2: ......
Relationship to Child: ......
Guardian No.2 Date of Birth: ......
Guardian No.2 CRN: ......
Address:......
......
Telephone (H):......
Mobile: ......
Workplace: ......
Telephone (W): ......
Email: ......
Medicare No.:......

Note: (please read and indicate accordingly): Under Australian Childcare Assistance Guidelines, it must

be noted the occupation of both parents. Please circle the category into which you fall. If one or both(1) Child at Risk

parents are working, please indicate your place of employment above. **Please note that (2) ‘Working’(2) Working/Training/Studying

can be on a part-time or full-time basis**(3) All other children

Is your family eligible for Child Care Benefit and/or Child Care Rebate? (Please tick) CCB  CCR 

Which CRN do you prefer to use to claim CCB and/or CCR? (Please tick) Guardian 1 Guardian 2

Who is liable for the cost of care and responsible for the payment of fees?(Please tick) Guardian 1 Guardian 2

Please note: You must notify the Centre ASAP of any changes in circumstances which may affect your payments of CCB and/or CCR. For example: number of children in care, family separation, JET eligibility. The Centre cannot guarantee backdating of payments if you fail to inform us of any changes.

SIBLINGS IN CHILDCARE (please supply documentation on enrolment):

Name: ...... Centre: ......

Name: ...... Centre: ......

Name: ...... Centre: ......

Please note: If you have more than one child in care, you must notify the Centre ASAP and provideyour multi child percentage rate to ensure that we can apply this to your fees. This includes families who have siblings that attend other child care provider’s services as well.

Continued Overleaf

PART 2 – ADDITIONAL & EMERGENCY INFORMATION

EMERGENCY CONTACT PERSON/S (OTHER THAN PARENTS):

Name:...... Telephone: ......

Address:...... Relation:......

Name: ...... Telephone: ......

Address: ...... Relation:......

Do you agree the above mentioned person/s has the authority to approve medical treatment?

Medical treatment for the child froma registered practitioner, hospital or ambulance service? YES/NO

Transportation of the child by ambulance service? YES/NO

Permission to attend Excursions or Regular Outings? YES/NO

AUTHORISED PERSON/S FOR DELIVERY & COLLECTION (OTHER THAN PARENTS):

Name:...... Telephone: ......

Address:...... Relation:......

Name: ...... Telephone: ......

Address: ...... Relation: ......

Do you agree the above mentioned person/s has the authority to approve:

Consent of medical treatment or to authorise administration of medication to the child? YES/NO

An educator taking your child outside the education and care service premises? YES/NO

Are there any custodial arrangements, current Court Orders, Parenting or Parenting Plans which may affect your child?YES/NO(If YES, please provide documentation at time of enrolment.)

Primary Language of Family: ...... Would you like our educators to communicate in your language? YES/NO

Special Cultural or Religious Requirements: ......

Does your child have any other special needs (including any previous illness or injury) with which the knowledge will assist us in our care? YES/NO. If YES, please provide details......

MEDICAL INFORMATION

Does your child suffer from any allergies? YES/NO. If YES, please provide details......

......

Dietary Requirements: As we provide meals, please indicate whether your child has any dietary requirements, food allergy or food intolerance. (Please also provide your medical practitioner, dietician or nutritionist’s plan):

………………………………………………………………………………………………………………………………………………….

………………………………………………………………………………………………………………………………………………….

If your child has a medical condition, we MUST have a management plan/anaphylaxis medical management plan?

Copy provided:Yes/No

Please provide a copy of your child’s health record. Copy provided: Yes/No

Has your child received all vaccinations relevant to his/her current age? Yes/No(please provide Vaccination Record upon enrolment).

 PolioTetanus Whooping CoughDiphtheria HibMeningococcalOther......

Family Doctor: ...... Practice: ......

Address: ...... Telephone: ......

......

EMERGENCIES

In the event of an accident or illness requiring emergency medical treatment, every effort will be made to contact the parents before such treatment is sought. However, should this prove impossible, it will be necessary for authority to be given for the treatment to be undertaken? This includes transport to an appropriate facility by car or ambulance. Parents are asked to complete and sign the following:-

I ______authorise the staff of Ally’s Kindy to seek emergency medical treatment for my child ______should this be necessary. This includes transport to the treatment centre (whether it be the doctor’s surgery or hospital) by car or ambulance if necessary. Furthermore, I have read and agree to abide by conditions of use of the Centre and to accept such responsibility as enrolment at the centre imposes.

Signed: ______Hospital I would like my child taken to:______

EMERGENCY CONSENT STATEMENT

“I ______(parent/guardian) consent to educators at Ally’s Kindy administering Ventolin and/or Epipen injection for ______(child’s name) when this is considered reasonably necessary in an emergency”.

Signed: ______

PANADOL

As stated in the Parent Handbook, I understand that in an emergency situation only, Panadol as a temperature reducing medication will be administered on a once only basis by staff of the Centre; and thereafter I will be responsible for consulting my medical practitioner. I hereby give my permission for the administration of the single dose.

Signed: ______

PART 3 – SIGNATURES

COMPLIANCE WITH HEALTH AND HYGIENE PRACTICES

I certify that I have read the relevant health and hygiene policies in operation at Ally’s Kindy (including those pertaining to medication and contagious illness) and that I agree to abide by these policies.

Signed: ______

PHOTOGRAPHS/WEBSITE

I give permission for Ally’s Kindy to take photographs of my child for the child’s development book, to display in my child’s classroom and hallways of the centre and to appear on the centre’s website.

Signed:______

LOCAL OUTINGS

I hereby give my permission for the staff of Ally’s Kindy to take my child on local (walking only) outings. This permission is also to include visits to shows or fire drill practices that occur in the car park of the Centre, and sibling or other visits between the Ally’s KindyRooms. (Parents will receive a separate form for excursions not in the local area).

Signed: ______

AFTER SCHOOL CARE(need only be signed by After School Care Parents)

I recognise that, whilst every care will be taken in picking my child up from our chosenPrimary School for after school care, on occasions when I have failed to notify Ally’s Kindy, that my child is not at school, or my child has taken it upon themselves to make alternative after school arrangements, they will only be held responsible for those children who have come into their care (as represented by the after school care sign-on sheet).

Signed: ______

WHERE DID YOU FIND US? (Please Circle)

FlyerInternet Magazine Adds Word of Mouth Face Book Other

Referral By:

PAYMENT OF FEES

I certify that I have read the relevant fee policies in operation at Ally’s Kindy and that I agree to abide by these policies and take responsibility for the payment of fees in agreement with the aforementioned Ally’s Kindy Fee Policy.

Print Name: ______

Signature: ______Date: ______

SIGNATURES

______

Guardian No.1Guardian No.2Date

PHOTOGRAPHS/FACEBOOK PAGE

I give permission for Ally’s Kindy to take photographs of my child for the Ally’s Kindy Face Book Page.

Signed: ______

We would like to welcome you to Ally’s Kindy and we thank you for entrusting us to

Care for your child. We hope your child will enjoy many happy

And treasured memories here and that your family’s stay with us

Will be a long and happy one.

“A GOOD BEGINNING NEVER ENDS”

PRE COMMENCEMENT CHECKLIST

Please ensure you have completed each section of the enrolment form and have included the following attachments:

  • Ezidebit Direct Debit Request Form...... 
  • Centrepay Request Form...... 
  • A current headshot photograph of child to be enrolled (can be emailed)...... 
  • Child’s health Record...... 
  • Medical Management Plan, Anaphylaxis Medical Management Plan

(If applicable)...... 

  • Dietician’s or Nutritionist’s Plan (if applicable)...... 
  • Custodial arrangements, current Court Orders, Parenting or

Parenting Plans (if applicable)...... 

  • Copy of your current Health Care Card (if applicable)...... 

INFORMATION ABOUT YOUR FEES

Fees at Ally’s Kindy are paid WEEKLY or FORTNIGHTLY via either Ezidebt or Centrepay (default of agreed payments for 2 consecutive weeks will result in your child’s days being forfeited.) If you are eligible, we estimate your fees to include your Child Care Benefit in advance. You will only need to pay the gap in outstanding fees.

IMPORTANT: Ensure that you have been in contact with the Dept. of Human Services (Centrelink) before you start care. Ask to be assessed for Child Care Benefit (CCB) and choose the reduced fees payment option. Do this even if your income is too high for CCB so that you can get Child Care Rebate (CCR).

Child Care Benefit (CCB) Helps with the cost of child care such as long, family or occasional day care, outside school hour care, vacation care, pre-school and Kindergarten

Eligibility Basics

  • Use approved or registered Child Care
  • Be responsible for paying the Child Care Fees
  • Have Immunised your child

Child Care Rebate (CCR) Covers 50% of out of pocket child care expenses, up to a maximum amount per child per year, in addition to any amount you may receive from Child Care Benefit and Jobs, Education and Training (JET) Child Care Fee Assistance.

Eligibility Basics

  • You use a Child Care Benefit approved child care service
  • You are eligible for Child Care Benefit for approved care, even if you earn too much to receive payment, and
  • You and your partner meet the Work, Training, Study test or are exempt from it

If you are eligible for the Child Care Rebate and choose to have the amount paid directly to the centre, the amount is paid in arrears (i.e. in the week following attendance)

For more information: