ENROLMENT FORM

1. CHILD’S DETAILS

Surname: ______/ Given Names: ______
Date of Birth: ______/ Age: ______
Sex: Male Female / Phone: ______
Address: ______
Is your child of Aboriginal or Torres Strait Islander origin?
No Yes, Aboriginal Yes, Torres Strait Islander
Child’s position in family: ______(e.g. eldest/youngest)
Number of children in the family:Boys: ______/ Girls: ______

2. ATTENDANCEPlease tick the appropriate days and service type required below.

Service Type / MONDAY / TUESDAY / WEDNESDAY / THURSDAY / FRIDAY
Babies Room 7.30 – 6.00
Long Day 7.30 – 6.00
Short Day 8.30 – 3.30
Exact arrival time
Exact departure time
Date required from: ______Enrolment date: ______
Reasons for attendance: (e.g. working, socialisation): ______

3. FAMILY DETAILS - Fees billed to parent registered for childcare benefit: Parent 1 Parent 2

PARENT 1.

Surname: ______/ Given Names: ______
Date of Birth: ______/ Licence Number: ______
Home Phone: ______/ Email Address: ______
Address: ______
Work: Full-time Part-timeCasual / Relationship to child: ______
Employers Name: ______/ Occupation: ______
Address: ______
Work phone: ______/ Mobile: ______/ Signature: ______

PARENT 2.

Surname: ______/ Given Names: ______
Date of Birth: ______/ Licence Number: ______
Home Phone: ______/ Email Address: ______
Address: ______
Work: Full-time Part-timeCasual / Relationship to child: ______
Employers Name: ______/ Occupation: ______
Address: ______
Work phone: ______/ Mobile: ______/ Signature: ______

OFFICE USE:Start date ______Attendance ______Child ID ______CCMS Form 

Birth cert.Immunisation copiedCourt order copiedDeposit Paid

Bond amount paid ______Date bond paid ______Bond refunded ______

FAMILY STATUS:

Marital status of parents:Married De facto  Widowed  Single Separated Divorced

If parents are separated or divorced, does the non-custodial parent have access to the child: ______

Details of access: ______

In the case of a court order restricting the access of either parent the Centre must witness the relevant court order. Without this the Centre is not legally able to deny access to either of the natural parents.

Is there a court order, parenting orders or parenting plans? YesNo Date sighted:______Copy on file:

The Centre cannot be a place of access for the child.

4. EMERGENCY CONTACTS

Contact with these persons will only be required when parents are unable toimmediately be contacted. Emergency persons must be able to be contacted by phone and be willing and able to collect the child if the parent is unavailable. These persons must be 18 years and over.

1.Surname: ______/ Given Names: ______
Home Phone: ______/ Work phone: ______/ Mobile: ______
Residential Address: ______
Relationship to child: ______/ Drivers Licence No: ______/ Signature: ______
2. Surname: ______/ Given Names: ______
Home Phone: ______/ Work phone: ______/ Mobile: ______
Residential Address: ______
Relationship to child: ______/ Drivers Licence No: ______/ Signature: ______

5. AUTHORISED NOMINEES TO PICK UP THE CHILD

The following persons (other than the parents) are authorised to collect the child under normal circumstances. These persons must be 18 years and over.

  • A person who has been given permission by a parent or family member to collect the child
  • A person who is authorised to consent medical treatment of or authorised administration of medication to the child
  • A person who is authorised to authorise an educator to take the child outside the premises

1. Surname: ______/ Given Names: ______
Home Phone: ______/ Work phone: ______/ Mobile: ______
Residential Address: ______
Relationship to child: ______/ Drivers Licence No: ______/ Signature: ______
2. Surname: ______/ Given Names: ______
Home Phone: ______/ Work phone: ______/ Mobile: ______
Residential Address: ______
Relationship to child: ______/ Drivers Licence No: ______/ Signature: ______

The child will be usually collected by: ______

If a person other than those listed above is to collect your child, parents must provide written permission to the Centre. Under emergency situations verbal permission may be accepted. Persons collecting the child will be asked to produce identification to staff upon arrival.

6. CHILDS HISTORY

HEALTH HISTORY:

Medicare Number: ______/ Health Fund: ______
Doctors Name: ______/ Phone: ______
Address: ______
Dentist Name: ______/ Phone: ______
Address: ______
Does your child suffer from any chronic illnesses? / ______
Any prescribed treatment/medication for the above? / ______
Is there any significant illness suffered in the past? / ______
Has your child been hospitalised for any reason? / ______
Does your child suffer from any proven allergies? / ______

Has your child been diagnosed with?AnaphylaxisAsthma

If yes, a copy of the current management plan must be completed and attached – this form can be obtained from the office.

Does your child have any special health requirements?

Hearing loss Blood disorder Epilepsy Convulsions  Heart murmur Diabetes

Cleft palate HerniaCroup  Poor vision  EczemaDevelopmental delays

If yes, please give details ______

SPECIAL NEEDS:

Does your child have any disability or other special needs (e.g. hearing, visual, physical, language/speech)?
______
At what age were these needs diagnosed/acquired? ______
Is their any special management or handling of your child required? ______
Are there any special agencies involved in the management of your child’s special needs?
(E.g. speech pathology, physiotherapy, etc.)? ______

If my child is or becomes enrolled with a special agency, I ______give permission for the Nominated Supervisor to liaise with the agency in order to provide the most beneficial program for my child. I understand that she/he will notify me of such contact as they occur.

IMMUNISATION RECORD:

Has your child had the following vaccinations? TICK if child has been immunised

2 MONTHS: DTP, Hep B, Hib, Polio, Pneumococcal, Rotavirus
4 MONTHS: DTP, Hep B, Hib, Polio, Pneumococcal, Rotavirus
6 MONTHS: DTP, Hep B, , Hib, Polio, Pneumococcal, Rotavirus
12 MONTHS: MMR, Hib, MenCCV
18 MONTHS: MMR, Varicella
4 YEARS: DTP, MMR, Polio

Please provide your child’s Immunisation History Statement issued by Australian Childhood Immunisation Register or Medicare for the Centre to photocopy.

OTHER:

Are there any special considerations for the child relating to culture, religion, and dietary requirements of additional needs we need to be aware of?

______

Is there anything in particular you feel the staff should know about your child?

______

Does your child have any particular fears?Yes No If yes, what are they? ______

Has someone else cared for your child? ______

Has your child attended another childcare centre? ______

Does you child celebrate: ChristmasBirthdaysEaster

How may we help your child this year? What would you most want for your child at this centre? Is there any particular area that concerns you that we need to know about? ______

______

7. COUNTRY OF ORIGIN

Mother: ______Father: ______Child: ______

How long has the family been in Australia? ______Languages spoken at home: ______

Signature of Mother/Guardian: ______Date: ______

Signature of Father/Guardian: ______Date: ______

8. PERMISSION DETAILS

Please indicate in the circles provided by colouring them in:

We ______and ______

  • Are aware of the Centre’s mandatory reporting obligations in relation to child protection and notification of suspected abuse. Signed: ______Signed: ______
  • Give permission for my nominated emergency contact persons to collect my child ______from the Centre if we cannot be contacted in the event of an emergency/accident/illness,

Yes NoSigned: ______Signed: ______

  • Understand that if anyone other than myself or my partner will be collecting my child we must inform the Centre beforehand  Y  N Signed: ______Signed: ______
  • Understand every possible care will be taken of my child while they are at the Centre. The staff in no way can be held responsible for any accident that occurs. In the event of an accident/illness requiring urgent medical/dental or hospital treatment, every effort will be made to contact my partner or I before the medical attention is sought. If we are unable to be contacted, it may be necessary for Oakville Playschool staff to give authority for immediate steps to be taken to secure that treatment and we agree to meet all expenses thereby incurred. Authority and consent to the medical treatment of my child ______for medical treatment from a registered medical practitioner, hospital or ambulance service and transportation of my child by a ambulance service.  Y N Signed: ______Signed: ______
  • Authorise staff of Oakville Playschool to seek and carry out appropriate emergency medical / hospital / dental treatment or ambulance service for my child ______should this be considered essential, Y  N Signed: ______Signed: ______
  • Hereby consent to our child’s photograph/name being used for publicity by the Centre if required and for the purposes of accreditation displays  Y  N Signed: ______Signed: ______
  • Hereby consent to our child being the subject of student/staff observations,

Y NSigned: ______Signed: ______

  • Understand that staff will take no responsibility for bottled milk and that we are responsible for its preparation and correct storage. Y  N Signed: ______Signed: ______
  • Give permission for staff to administer one prescribed dosage of Panadol as stated on the bottle, to our child if the temperature rises above 38.5ºC. I understand that every attempt will be made to contact me prior to administering this, Y N Signed: ______Signed: ______
  • Agree that if my child is suffering from a contagious illness that they will not return to the centre until cleared by a medical practitioner and that the medical certificate in supplied to confirm this,

Y NSigned: ______Signed: ______

  • Give permission for staff to use zinc & castor oil cream/baby powder/baby wipes supplied the centre, otherwise we will supply them ourself with a Doctors prescription/letter

Y N Signed: ______Signed: ______

  • Hereby give permission for the staff of the Centre to apply sunscreen to our child,

 Y NSigned: ______Signed: ______

  • Give permission for staff of Oakville Playschool to check my child’s hair for head lice during outbreaks. Y  N Signed: ______Signed: ______
  • Understand and accept that fees for our Centre are payed weekly on the child’s first day of attendance for the week, Y  N Signed: ______Signed: ______

Signature of Mother/Guardian: ______Date: ______

Signature of Father/Guardian: ______Date: ______

CONDITIONS OF ENROLMENT:

  • An establishment fee of fifty dollars ($50.00) is payable at the time of enrolment and this is non-refundable. New enrolments must pay at the time of their interview if the spot is confirmed, plus $200 bond. Enrolments for the following year must pay establishment fee and two hundred ($200) bond before the first (1st) of December. If payment is not received your child’s placement will be cancelled. Parents are to then make another payment on your child’s first week of attendance.
  • If fees are in arrears for 2 weeks and no arrangement has been made with the Centre Authorised Supervisor, my child’s place will be withdrawn until arrears payment finalised. Failure to make a payment will lead to cancellation of your child’s placement. Should I fail to pay my fees and my place is withdrawn, I will be liable for all additional costs incurred by the Centre in collecting these outstanding fees.
  • Fees are payable for your child’s confirmed days of enrolment and need to be paid even if your child does not attend due to illness, flood, personal holidays and public holidays. Fees are not charged over the four (4) weeks closure over the Christmas break.
  • A minimum of two (2) weeks notice is required for cancellation of enrolment. Parents are required to notify the Director in writing of the termination of care.
  • Oakville Playschool operates for 48 weeks per year (four (4) week closure over Christmas and New Year) and fees will be charged in full for forty eight (48) weeks of the year. Operational hours are from seven thirty (7.30am) to six (6pm).
  • A late fee will be charged for children who are not collected by 6pm, the rate being a $10.00 late fees and $1 a minute for every minute late. Parents who consistently pick their child/ren up late should seek alternative childcare arrangements.
  • If for any reason a child has not been collected by 6.00pm on any evening and the Centre has not been notified by the parent or nominated authority, then the Centre may contact the Department of Community Services Help Line on 13 21 11 and they will send the police to collect the child.
  • Allocated days of attendance are permanent, not flexible and transferable.
  • The Federal Government has ‘Priority of Access’ for long day child care centres. Childcare placements at the Centre are allocated to families where children who have the highest priority.

Priority 1: Children with parents working, seeking employment or studying/training.

2: Children or parents with a continuing disability.

3: Children at risk of serious abuse

4: Children of parents who are at home with more than one child under school age, or single parent.

  • The Centre must be informed immediately of any changes to detail contained on the enrolment form.
  • All parents must acknowledge that they fully understand and agree to abide by all conditions in this form, parent handbook and the Policies of the Centre, as amended by the Centre from time to time.
  • If you decide to withdraw your child or reduce days, you must give the Director two (2) weeks notice, and/or fill in a resignation form. Notice of cancellation will be effective two (2) weeks from parent informing Director or completing form. If 2 weeks notice occurs after the 1st of November, fees will be incurred until the Centre’s closure at Christmas. If 2 weeks notice occurs the last week before the Centre’s closure at Christmas or in the first week of opening for the year, the child’s bond will be forfeited.
  • Enrolments for a new year are offered firstly to existing children and their siblings, and then to children on the waiting list in order that their name appears.
  • Oakville Playschool fees:

Yellow baby’s room daily rate is $80.00 per day.

Yellow toddler room daily rate is $75.00 per day.

The Centre provides parents in the 3-5 year room with a choice of two time slots:

Short Preschool Day 8.30am - 3.30pm: $70.00

Long Day 7.30am - 6.00pm: $75.00

We (Mother/Guardian) ______and (Father/Guardian) ______

have read and understand these conditions of enrolment and will follow these at all times.

Signature of Mother/Guardian: ______Date: ______

Signature of Father/Guardian: ______Date: ______

Thank you for taking the time to complete this enrolment form which will help us to better care for your child. Please ensure that you have the following documents with you before returning your enrolment form:

Enrolment formChild care benefit detailsAustralian Immunisation Register History Statement

Birth certificateDeposit and bondAsthma/anaphylaxis/dietary letter or court order

Updated 29.08.04, 18.07.05, 08.02.06, 03.05.06, 31.08.06, 18.07.07, 11.02.08, 15.04.09, 31.05.10, 09.02.11, 24.02.11, 16.2.12, 22.02.12, 24.04.12, 08.11.12, 14.11.12, 11.04.13, 01.07.13, 27.03.14