Mount Colah After School Care Association Inc

Enrolment Form

19-21 Telopea St, Mount Colah | service@mtcolahoshc.com.au

Child's Details

Given Name

Family Name

Date of Birth *

Child's CRN *

Gender

Street address

City

State

Postcode

Cultural Background

Language Spoken

Indigenous Status

Any special considerations e.g. cultural, religous, customs, dietry?

Are there any court orders, parenting orders or parenting plans relating to the powers, duties, responsibilities or authorities of any person in relation to the child or access to the child? If yes, please give current details and provide photocopies of any court orders.

Days of Attendance

Family Details

Primary Parent/Carer

Primary Parent/Carer is the person linked to the child according to Centrelink records. Please note Parent/Carer and child have their own individual CRN number.

Given Name

Family Name

Date of Birth *

CRN *

Street address

City

State

Postcode

Contact No.

Email

Cultural Background

Language Spoken

Indigenous Status

Priority of Access (Employment Status)

Secondary Parent/Carer

Given Name

Family Name

Date of Birth

Street address

City

State

Postcode

Contact No.

Email

Cultural Background

Language Spoken

Indigenous Status

Priority of Access (Employment Status)

First Emergency Contact/Authorised Nominee

Please nominate two people’s contact details that you authorise to collect your child and/ or contact in case of an emergency. It is your responsibility to inform these people that they have been listed as your child’s emergency contact or authorised nominee. Emergency contacts and authorised nominees must provide photo identification upon request

Full Name *

Relationship to Child

Contact No. *

Street address

City

State

Postcode

This person has permission for the following

Collect your child or authorise another person to collect your child from the serviceAuthorise an educator to take your child on excursions/ activities/ regular outings from the serviceConsent to medical treatment by a medical practitioner, hospital or ambulance service and/or transportation by ambulance service for your child Consent to medication being given to your child Be notified of an emergency involving your childAuthorise the education and care service to transport the child or arrange transportation of the child

Second Emergency Contact/Authorised Nominee

Full Name *

Relationship to Child

Contact No. *

Street address

City

State

Postcode

This person has permission for the following

Collect your child or authorise another person to collect your child from the serviceAuthorise an educator to take your child on excursions/ activities/ regular outings from the serviceConsent to medical treatment by a medical practitioner, hospital or ambulance service and/or transportation by ambulance service for your child Consent to medication being given to your child Be notified of an emergency involving your childAuthorise the education and care service to transport the child or arrange transportation of the child

Health and Medical Information

Medicare No. *

Medicare Exp *

Child's Registered Medical Practitioner or Service Name

Contact Numbers

Child's Registered Dental Practitioner or Service Name

Contact Numbers

Medical Condition and Illness

Does your child have Anaphylaxis? *

YesNo

If YES, attach an ASCIA Action Plan for Anaphylaxis Reactions form (Found at ASCIA www.allergy.org.au ). Have the forms signed by your child's doctor

Browse

Does your child have any allergies? *

YesNo

If YES, attach an ASCIA Action Plan for Allergic Reactions form (Found at ASCIA www.allergy.org.au ). Have the forms signed by your child's doctor

Browse

Does your child have Asthma? *

YesNo

If YES attach an Asthma Australia Asthma Care Plan for Education and Care Service form Reactions form (Found at Asthma Australia - www.asthmaaustralia.org.au ). Have the forms signed by your child's doctor

Browse

Does your child have another medical condition not listed above (for example diabetes, epilepsy, hearing loss, etc)? *

YesNo

Please Specify

Please provide any necessary documentation

Browse

Is there any particular area of development that concerns you about your child? This may be behavioural (for example ADD, ADHD, Autism Spectrum Disorder, etc), physical, emotional or social? Are there any special care instructions that may assist us in caring for your child?

Please provide any details that may assist us in ensuring the safety and wellbeing of your child

Parent/Carer Permissions

In the event of an emergency the service may seek medical treatment from a registered medical practitioner, hospital, or ambulance service (including transportation by an ambulance) in the event that my child has been injured or become ill at the service. I accept any liability for medical, dental, hospital and ambulance that may be incurred. Note: Your child enrolment will not be accepted unless agreed.

YesNo

If my child has a temperature higher than 38.5 Celsius a staff member may administer a single dose of paracetamol e.g. Panadol. The service will attempt to contact me before the administration of the medication. I will arrange to collect my child as soon as practical.

Yes No

That my child’s Medical Management Plan (if applicable), that contains personal health information, can be displayed and readily visible for people who access the service, so staff can access this information with ease, if an emergency response is required.

YesNo

For the service to use SPF 30/50+ broad-spectrum, water resistant sunscreen on my child’s face and exposed limbs. Where my child is allergic or sensitive and requires special sunscreen I/we will provide an alternative.

YesNo

For the service to apply appropriate insect repellent e.g. RID, to the exposed limbs of child where needed.

YesNo

Give permission to the service that my child’s art work, photographs, video and/or sound recordings that have been taken individually or in a group at the service, excursions and/or any other related events may be used for publications such as service & school newsletters, and for the purpose of documenting children's learning

YesNo

Give permission for my child to use technology in the form of and not limited to computer, iPad at Mount Colah After School Care Association Inc. I understand my child will be supervised at all times and these devices will be used appropriately for educational and/or leisure purposes

YesNo

Give permission for my child to watch G rated movies/animations.

YesNo

Give permission for my child to watch PG rated movies/animations.

YesNo

To abide by the policies and procedures in place by Mount Colah After School Care Association Inc. and accept their conditions. I understand that a hard copy of the Mount Colah After School Care Association Inc. policy manual, is available for viewing at the service at all times. I understand that a PDF version can be emailed to me upon request

YesNo

Parent/Carer Declaration and Agreement

All information given in this enrolment form is true and correct. I/we will inform Mount Colah After School Care Association Inc. in the event of any change to this information. I/we understand that my/our child’s enrolment will not be valid unless this enrolment form is entirely completed.

I/we will give 2 weeks required written notice (during service operating days) when withdrawing my child from the service. We understand that I/we are responsible for paying all fees during the notice period regardless of my child/ren attending the service or not.

I/we are liable for all fees associated with our child’s enrolment at the service and understand that I/we are responsible for updating our Child Care Subsidy (CCS) information (if applicable) whilst the child is in care. In the event that I/we are no longer eligible for CCS I/we will be required to pay full fee.

I/we understand that Under the Children and Young Persons (Care and Protection) Act 1998, Chapter 16A, information may be shared with other prescribed agencies that relate to the current welfare, wellbeing and safety of children in our care. Staff at Mount Colah After School Care Association Inc. adhere to the Privacy Act and all Service Policies and Procedures. I understand that all staff at the service are mandatory reporters under the Children and Young Persons (Care and Protection) Act 1998, and are bound by law to report any matters of concern in relation to my child.

Parent/Carer Name

Parent/Carer Signature

Draw signature|Type signatureClear

Date