Waimate Kindergarten Association MOBILE ENROLMENT FORM (Playgroup) CONFIDENTIAL
Kindergarten:
Date of Enrolment:____ /____ / __ / Date of Entry: ____ /____ / ____ / Date of Exit: ____ /____ / ____
Note: Any changes to the original enrolment agreement form must be signed and dated by the parent/guardian.
Child:
Child’s first names: / Surname:
Name your child is known by:
Child’s date of birth: / Male / Female
Ethnic origin:
Iwi your child belongs to:
Languages spoken:
School likely to attend:
Child’s home address or addresses:
Parents / Guardians – (primary caregiver and child’s usual home address)
First Names: / Phone (Home):
Surname: / Phone (Work):
Address: / Phone (Mobile):
Email:
Relationship to Child
Post Code / Occupation
Parents / Guardians
First Names: / Phone (Home):
Surname: / Phone (Work):
Address: / Phone (Mobile):
Email:
Relationship to Child
Post Code / Occupation
Signed by Parent/Guardian ______
Date: ______
Emergency Contacts:
First Names: / Phone (Home):
Surname: / Phone (Work):
Address: / Phone (Mobile):
Email:
Post Code:
Relationship to Child:
Custodial Statement
Are there any custodial arrangements concerning your child?
If YES, please give details of any custodial arrangements or court orders (a copy of any court order is required)
Doctor:
Name: / Phone:
Address:
Health
Illness/allergies:
Is your child up-to-date with immunisations? / Tick One / Yes / No
(Please provide verifications of all immunisations)
Immunisations record sighted and details recorded: / Tick One / Yes / No
Medicine
Category (i) Medicines
A category (i) medicine is a non-prescription preparation (such as arnica cream, antiseptic liquid, insect bite treatment) that is not ingested, used for the ‘first aid’ treatment of minor injuries and provided by the service and kept in the first aid cabinet.
Note: The service must provide specific information about the category (i) preparations that will be used
Do you approve category (i) medicines to be used on your child? / Tick One / Yes / No
Name/s of specific category (i) medicines that can be used on my child, provided by service:
- Sodium Chloride Irrigation Solution
- Skin Prep – antiseptic skin cleansing wipes
Parent/Guardian Signature: ______/ Date: ____ /____ / ____
Enrolment Details:
Days Enrolled: / Monday / Tuesday / Wednesday / Thursday / Friday
Times Enrolled: / Total number of hours:
Parent/Guardian Signature: ______/ Date: ____ /____ / ____
Parent/Guardian – Statement of Understanding:
I understand and agree that sections of legislation require the Kindergarten to provide my name and telephone number to agencies such as the NZ Police, Child Youth & Family, and Work & Income, if requested. / Yes No
I give permission for my child’s details to be given to:
- the school for roll predictions;
- any visiting health professionals and or education specialists;
- the kindergarten committee for fundraising purposes;
I understand that the Waimate Kindergarten Association has a number of procedures that set out the procedures that are in place for the care and education of the children who attend. We strongly urge you to read these. The signing of this enrolment agreement form indicates that you will abide by the procedures of this service, and understand who you can have input to procedure/policy review. / Yes No
I give permission for this child to be photographed or videoed at the kindergarten for learning related purposes and/or publicity purposes. This will include the processes of assessment, planning and evaluation. I understand that other families will have access to these. / Yes No
I give permission for my child to be observed by students and other training professionals. / Yes No
I give permission for this child to be involved in the use of ICT including use of suitable internet sites for educational purposes with teacher supervision. I understand observations of my child will be made by the staff and teachers. / Yes No
Parent Declaration
I declare that all the above information is true and correct to the best of my knowledge, and I understand I am responsible for my child at all times during the Mobile Kindergarten Session we attend.
Parent/Guardian Signature: ______/ Date: ____ /____ / ____
Service Declaration
On Behalf of the Waimate Kindergarten Association I declare that this form has been checked and all relevant sections have been completed.
Service Provider Signature: ______/ Date: ____ /____ / ____
1
November 2014