Child Profile

School Holiday Program

Your child’s health and wellbeing are our priority. Information on this form will assist staff in

supporting your child’s inclusion in the School Holiday Program.

If there is insufficient room on this form please attach additional information.

Note: An Application for Enrolment should either precede or accompany this form.

CHILD’S NAME:______

DATE OF BIRTH:______

HOME ADDRESS: ______

PERSON COMPLETING FORM: ______

RELATIONSHIP TO CHILD: ______

PLEASE DESCRIBE (and name where relevant) THE CHILD’S ADDITIONAL NEEDS OR DISABILITY

______

______

PLEASE DESCRIBE (and name where relevant) THE CHILD’S MEDICAL CONDITION(S)

______

______

Does your child require medication to be givenat the programYesNo

If yes, please identify ______

If your child requires medication whilst at the program a medication administration form must be completed EACH day at the program.

Diet RestrictionsYesNo

If yes, please identify ______

WHAT LEVEL OF SUPPORT DO YOU BELIEVE YOUR CHILD NEEDS TO PARTICIPATE IN THE SCHOOL HOLIDAY PROGRAM?

Constant one on one support to participate in activities

Minimal support by increased child/staff ratios to participate in activities

Interacts in an age appropriate manner with other children, using standard ratios (eg 1 adult to 15 children)

INDEPENDENCE SKILLS

Physical Participation:

My child is able to

Open doors without assistanceYesNo

Engage in tasks independentlyYesNo

Participate in craft activitiesYesNo

Climb unassistedYesNo

Participate in bat and ball gamesYesNo

Details of support required ______

Mobility

My child:

Uses a wheelchairYesNo

Can crawl independentlyYesNo

Can walk independently up and down stairsYesNo

Requires assistance on walking tripsYesNo

Details of support required ______

Self Care

My child:

Indicates their needs verballyYesNo

Will require assistance with going to the toiletYesNo

Wears nappies/pull ups/padsYesNo

Requires 2 staff to change nappiesYesNo

Takes themselves to the toiletYesNo

Can wash hands independentlyYesNo

Requires assistance dressing and undressingYesNo

Understands climate appropriate dressYesNo

Is able to complete tasks for buttons and zipsYesNo

Is able to indicate their need for food and drinkYesNo

Is able to feed themselves independentlyYesNo

Is able to access food from a bagYesNo

Is able to drink from a cupYesNo

Is PEG fedYesNo

Requires supervision during meal timesYesNo

Details of support required ______

COMMUNICATION

My child:

Can communicate verballyYesNo

Understands verbal instructionsYesNo

Makes eye contactYesNo

Understands non verbal communicationeg hand gesturesYesNo

Primary language spoken______

Does your child require communication aids YesNo

If yes state type

MakatonCompicBoard Maker/Cars/Pictures

AuslanOther ______

Details of support required and strategies used ______

BEHAVIOURAL AND SAFETY NEEDS

How does your child respond in social situations?

Shy in new environmentsYesNo

Understands rules and boundariesYesNo

Engages in solitary play onlyYesNo

Engages in play with other childrenYesNo

Understands the concept of sharingYesNo

Requires close supervision in public areas YesNo

Requires close supervision with access and exit doorsYesNo

Has age appropriate road senseYesNo

Understands concept of stranger dangerYesNo

Able to climb equipmentYesNo

Able to cope with loud noiseYesNo

Able to cope with new, large open space environmentsYesNo

Able to sit for a bus tripYesNo

Able to sit through a movie at the cinemaYesNo

Does your child display the following anti social behaviour?

KicksYesNo

HitsYesNo

SpitsYesNo

BitesYesNo

SwearsYesNo

Self harming behaviourYesNo

AbscondingYesNo

Sexualised behaviourYesNo

Does the child display any other challenging behaviourYesNo

Please provide strategies to deal with any checked YES above ______

______

Does your child have a behaviour management plan at home/school?YesNo

If yes, please attach.

HOW DOES YOUR CHILD DEMONSTRATE FRUSTRATION OR DISTRESS?

______

______

WHAT STRATEGIES ARE SUCCESSFUL IN CALMING YOUR CHILD IN THESE SITUATIONS?

______

______

WHAT OTHER SERVICES DOES YOUR CHILD RECEIVE SUPPORT FROM?

(special services, school services, specialists, therapists, occupational therapists, speech therapist, psychologist etc)

Organisation / Contact Person / Contact Details / Nature of Support

Please provide any other information about your child that may be relevant to the provision of child care within the school holiday program setting.

______

______

______

______

I agree that

  • I have provided sufficient information regarding my child’s health and additional needs for Council to be able to make an assessment to determine the ability of the program to meet the needs of my child.
  • The above information is a true and accurate reflection of the needs of my child.
  • The officers of the City of Greater Geelong have my permission to clarify with third party agencies listed on this form, information regarding the needs of my child.
  • I understand that my application may be refused in the event of the non disclosure of relevant information.

Name:______

Signature: ______

Date:______

Privacy Statement

The City of Greater Geelong considers that the responsible handling of personal information is a key aspect of democratic governance, and is strongly committed to protecting an individual’s right to privacy. Council will comply with the information Privacy Principles as set out in the Information Privacy Act, 2000. The personal information required on forms used will only be used by Council for the purpose of provision of Education and Care Early Years’ services. The information will not be disclosed to any other party unless Council is required to do so by law. You can view and change the information by contacting your Education and Care Service.

HOW TO KEEP ______SAFE

Please provide detailed information. This page will be placed on staff notice boards for easy access.

If my child….. / Please follow the following steps:
ABSCONDS
WANDERS
RUNS AWAY / 1.
2.
3.
4.
5.
USES INAPPROPRIATE LANGUAGE / 1.
2.
3.
4.
5.
HITS
PUNCHES
KICKS
BITES / 1.
2.
3.
4.
5.
GOES ON EXCURSION / 1.
2.
3.
4.
5.

The best person to contact if my child is distressed is:

______

The best activity for my child when distressed / anxious is:

______

The best thing to say to my child to calm him/her down is:

______

Any further information?

______

______

______

______