This Form Must Be Completed by a Parent for Each Child Enrolled in the Education and Care

This form must be completed by a parent for each child enrolled in the Education and Care Service

(the Service).If you require assistance completing this form, please contact City of Casey Family Day Care on 9705 5200.

1. Information about the child - please print clearly

Given name/s: ______

Family name: ______

Date of birth: ______Gender:  Male  Female

Child’s home address ______

______

Language(s) spoken in the child’s home: ______

Cultural background (if applicable):______

Is the child of Aboriginal and/or Torres Strait Islander origin?  Yes  No

1. Information about the child’s parents - Persons with Authority

Parents

The definition of the ‘parent’ according to National Law is:

»(a) a guardian of the child; and

»(b) a person who has parental responsibility for the child under a decision or order of the court.

Parent’s partners:

A relationship that arises by marriage (including a de facto relationship) cannot be included as a ‘parent’ unless the person has obtained parental responsibility for the child under a decision or order of a court.

Family members:

Other persons such as family members other than parents, with whom the child permanently resides, also fall within the definition of a ‘family member.’ Unless they have sought legal guardianship or have obtained parental responsibility for the child under an order or decision of the court, they cannot be listed as a parent.

Educator/Staff Use only: additional information enclosed in this record:

Dietary Restrictions  / Photo Consent Restrictions  / Court Orders/Parenting Plans 
Medical Conditions  / Non-immunised/catch up program  / Other:

Parent 1

Given name: ______

Family name: ______

Relationship to child:  Mother  Father  other: ______

Does the child live with this parent?  Yes  No

Address same as child:  Yes or: ______

Home phone: ______Mobile phone: ______

Work phone: ______Email address: ______

Hours of work/study:  Full time  Part Time  Casual

Name and location of work/study place: ______

______

Language(s) spoken by the parent:______Interpreter required  Yes  No

Parent 2

Given name: ______

Family name: ______

Relationship to child:  Mother  Father  other: ______

Does the child live with this parent?  Yes  No

Address same as child:  Yes or: ______

Home phone: ______Mobile phone: ______

Work phone: ______Email address: ______

Hours of work/study:  Full time  Part Time  Casual

Name and location of work/study place: ______

______

Language(s) spoken by the parent: ______Interpreter required  Yes  No

1. Court orders, parenting orders or parenting plans relating to the child

(a)Are there any court orders, parenting orders or parenting plans relating to the powers, duties and responsibilities or authorities of any person in relation to the child or access to the child?

 No Yes, please attach

(b)Are there any other details of court orders relating to the child’s residence or the child’s contact with a parent or other person?

 No Yes, please attach

1. Authorisations: details of people the parent authorises as contacts for the child other than those listed as parents in section two

Definitions

»Authorised to collect (Authorised Nominee) the child from the education and care service

»Authorised to be notified of an emergency involving the child if any parent cannot be contacted

»Authorised to consent to medical treatment

»Authorised to consent to administration of medication

»May authorise an educator to take the child outside of the service on excursions/regular outings

»May authorise an educator to take the child outside of the service premises

List the details of those persons who you authorise as contacts for the child. Please complete all fields. The list may be amended at any time. An additional copy of this page can be obtained from the educator.

I ______(Print full name) nominate the person/s listed below as authorised contacts for the child.

Parentsignature: ______Date ___ /___ /___

Contact 1: (not including those listed as parents in section two)

Full name:______

Address: ______

Home phone: ______Work phone: ______

Mobile phone: ______Relationship to child:______

Please tick the box/es below to confirm the level of authorisation you give to this person

 Authorised to collect (Authorised Nominee)

 Authorise to be notified of an emergency involving the child if any parent cannot be contacted

Authorised to consent to medical treatment

Authorised to consent to administration of medication

May authorise an educator to take the child outside the service on excursions/regular outings

May authorise an educator to take the child outside the service premises

Contact 2 (not including those listed as parents in section two)

Full name:______

Address: ______

Home phone: ______Work phone: ______

Mobile phone: ______Relationship to child:______

Please tick the box/es below to confirm the level of authorisation you give to this person

 Authorised to collect (Authorised Nominee)

 Authorise to be notified of an emergency involving the child if any parent cannot be contacted

Authorised to consent to medical treatment

Authorised to consent to administration of medication

May authorise an educator to take the child outside the service on excursions/regular outings

May authorise an educator to take the child outside the service premises

1. Attendance at another children’s service

Does the child attend another child care, outside school hours, family day care or kindergarten service?

NoYes If yes, provide details:

Service name:______

Days/times of attendance: ______

1. Child’s immunisation and health information

Immunisation

By law, the service is required to obtain evidence of immunisation. Acceptable documentation includes one of the following.

»Immunisation History Statement– issued by the Australian Childhood Immunisation Register

»Immunisation Status Certificate– Issued by the child’s Immunisation Provider

Immunisation records that are not acceptable as evidence of the child’s immunisation status include:

»the child’s Health Record(blue book) Health & Development Record (green book)

»overseas immunisationrecords

»‘homeopathic immunisation’

»statutory declarations

»DHS Medicare repository Services immunisation encounters

Conscientious objection and vaccination objection on non-medical grounds are not valid exemptions from immunisation requirements.

Immunisation History Statements can be requested at any time by contacting Medicare:

1

»Phone 1800 653 809

»Email

1

»Visit the Medicare website

»Visit your local Medicare office.

1

A copy of the child’s immunisation statusis attached  Yes  No

Medical

Name of doctor:______

Name of medical service: ______

Address: ______

Telephone: ______

Child’s Medicare No. (If available):______Not available 

Maternal & Child Health Centre: ______

Child’s specific medical conditions

Medical Conditions
Has the child been diagnosed as being at risk of anaphylaxis?  Yes No
Has the child been prescribed an adrenaline auto-injector device?(AAID)  Yes No
Has the child been diagnosed with asthma?  Yes No
Has the child been diagnosed with epilepsy?  Yes No
Has the child been diagnosed with diabetes?  Yes No
If yes to any of the above, the parent is required to provide anAction Plan (available from a medical practitioner) specific to the child’s diagnosed conditionthat has been completed by the medical practitioner
You will be provided with a copy of the City of Casey Child Youth & Family Guidelinerelevant to the medical conditionandaRisk Minimisation & Communication Planto be completed with the educator before the child commences care.
Allergies
Does the child have any diagnosed allergies?Yes No
If yes, please request a City of Casey Allergy Management Planfrom the City of Casey to be completed by a medical practitioner.
The City of Casey will also provide a copy of the City of Casey Allergy Management GuidelinesandanAllergy Risk Minimisation & Communication Plan to be completed with the educator before the child commences care.
DietaryRestrictions
Does the child have any dietaryrestrictions?(including cultural or religious considerations)
Yes  No
If yes, please request a Dietary Restrictions form from the City of Casey to complete.

7. Child’s Cultural/Religious/Specific Health Care/Developmental Needs

The City of Casey is committed to providing an environment that values and respects the needs of all children to fully participate. The programs are planned to accommodate the individual needs of all children

»Does the child have any additional health care needs, medical conditions or
diagnosis that are relevant to the education and care of the child?......  Yes No

»Do you have any concerns regarding the child’s development......  Yes No

»Do you believe the child may need any other additional support or guidance
to participate fully in the program?......  Yes No

»Are special cultural or religious considerations required for the child/family?......  YesNo

If you have answered yes to any of the questions above please provide details below, to assist educators to maximise the child’s participation and ensure full inclusion. If required attach a separate page.

______

______

______

______

______

______

______

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Is the child linked to other professional services e.g. paediatrician, early intervention service,
therapists, Preschool Field Officers, Inclusion Support Facilitator:

Professional service name: ______

Contact name and details: ______

Do you authorise the educator to communicate with this service to support the child’s health and wellbeing?  Yes No

Professional service name: ______

Contact name and details: ______

Do you authorise the educator to communicate with this service to support the child’s health and wellbeing?  Yes  No

8. Request for educators to apply sunscreen

A parent’s consent is required before sunscreen can be applied to the child.

»Thisauthorisation remains valid until such time that the parent notifies the educator in writing of change.

»It is the responsibility of the parent to ensure that the sunscreen is provided daily between September and April and at other times as required.

»Parents are to ensure that the sunscreen is applied to their child at least 20 minutes before arrival at the service and the educator will supervise further applications as required throughout the day in accordance with the Weather Protection Guidelines

»The sunscreen provided should be clearly labelled with the child’s name, be a minimum of 30+ and within expiry or use by date.

»Parents are responsible for the replacement of any used or out of date sunscreen.

»The educator will advise the parent if the sunscreen needs replacing.

»Parents and educators must notify each other immediately if there is any evidence of an allergic reaction following the application of sunscreen.

»Children over four years will be encouraged to apply their own sunscreen under supervision.

 I authorise the educator/s at my child’s service to apply the sunscreen I have provided for my child as required and in accordance with the instructions contained in the Weather Protection Guidelines

 I authorise the educator/s at my child’s service to apply sunscreen provided by the service in the event that I have not provided my child’s own, in accordance with the instructions within the Weather Protection Guidelines. I understand that the brands used may vary according to availability.

9. Filming/Photography Consent

A parent’s consent is required before taking images or recordings of their child.
In line with the City of Casey Children’s Plan, Children’s Services advocate for the rights of each child as a valued member of the community. Staff and educators of the City of Casey will engage in verbal consultation with children that is respectful, ethical and genuine prior to any filming or recording of them.

Specific agreement

By signing this form, I understand and give permission for myself and/or the child to be filmed and/or photographed and the images obtained, used in accordance with my selection below.

Within the children’s service (FDC educator residence):

»program documents, newsletters, child’s portfolio, wall displays......  YesNo

»electronically provided to me (the parent) containing images of the child......  Yes No

»electronically provided to other parents that may contain images of the child......  Yes No

City of Casey use outside of the children’s service:

»power point presentations at meetings and training......  Yes No

»playgroups, family events and celebrations......  Yes No

»newsletters, brochures, journals......  Yes No

»educator/ staff emails......  YesNo

»advertising in newspapers, websites and other media outlets......  Yes No

»media and publications (e.g.; the City of Casey website, annual report,
Children’s Plan, brochures and banners)......  Yes No

Please indicate for whom your permission applies:

»Myself......  Yes No

»The child as listed on this Child’s Confidential Record......  Yes No

I ______(insert full name) understand that:

»when I receive images electronicallyand there are other children in the image I cannot forward these images or use them without the permission of the families in the image

»the child’s first name and age may be used to acknowledge any of the child’s images if they are published

»the images may be used in new publications by the City of Casey for the duration of two years

»the child and I are able to withdraw our consent at any time

»the City of Casey will maintain confidentiality of both my and the child’s information along with any of our images

»if photo consent is required that does not fall within the above parameters, the educator will obtain specific consent to suit the individual circumstances

»the City of Casey will respect my right to not provide consent but cannot always prevent members of the public or other families from taking images of myself or the child at kindergarten events such as end of year celebrations

Parent full name: ______

Parent signature: ______Date ___ /___ /___

10.Scheduled care required – parent to complete

Have you previously registered with the City of Casey Family Day Care Scheme?  Yes  No

Commencement date requested: ___ /___ /___

Type of care required (please tick options below)

 Booked Care  Before and After School Care  Casual Care  School Holiday Care

Actual hours of care required for the non-school child: (minimum of 5 hours)

Mon / Tues / Wed / Thurs / Fri / Sat / Sun
Care start time
Care finish time

Do you require the educator to drop off or collect the child from kindergarten?  Yes  No

If yes, name and suburbof the kindergarten: ______

Mon / Tues / Wed / Thurs / Fri / Sat / Sun
Drop of time
Collection time

Actual hours of care required for the school child: (minimum of 2 hours)

Do you require your child to be dropped off or collected from school?  Yes  No
If yes, name and suburbof the school: ______

Mon / Tues / Wed / Thurs / Fri / Sat / Sun
Before school care start time
School drop off time
After school collection time
After school care finish time

Do you require care during school holidays?  Yes  No

Mon / Tues / Wed / Thurs / Fri / Sat / Sun
Drop off time
Collection time

11. Child Care Benefit and Child Care Rebate

In order for the service to provide Child Care Benefit (CCB), the person applying for CCB must provide their Customer Reference Number (CRN) and the CRN of the child.

Name of the person who is registered/applying for CCB:

Parent full name: ______Relationship to child: ______

Parent date of birth: ______CRN: ______

Child’s full name: ______CRN:______

12. Declaration and Consent

I ______(print full name) the

person having authority for the child referred to in this Child’s Confidential Record:

»declare that the information in this Child’s Confidential Record is true and correct and undertake to immediately inform the educators at the service in the event of any change to this information

»understand that in an emergency situation or drill where evacuation is necessary that the child may need to leave the service under the direction and supervision of the educators

»authorise the approved provider, nominated supervisor or educators at the service to seek necessary medical treatment for the child from a registered medical practitioner, hospital, dental or ambulance that includes the transportation of the child by an ambulance from the service in the event of an emergency. I agree that all associated medical expenses will be my responsibility.

»understand that the City of Casey complies with the Information Privacy Act 2000 in relation to the collection of information contained within this Child’s Confidential Record

»have read the service information on the City of Casey website and understand the conditions under which I am enrolling the child and will abide by the fee payment terms

Parent full name: ______

Signature: ______Date: ______

Parent 2 (optional) full name: ______

Signature: ______Date: ______

Privacy Statement
Your personal information will be handled in accordance with the Privacy and Data Protection Act 2014 and used for the specified purpose. You can access your personal information by contacting Council’s Privacy Officer on 9705 5200

13. Office/educator use

Family ID: ______Child Number: ______

ECM ID: ______Date of Application: ______

Immunisation assessment

Acceptable evidence of the child’s immunisation status is attached to this record  Yes

The child is eligible for the 16 week Grace Period. Yes

The Immunisation grace period eligibility assessment formis attached  Yes

First Review of immunisation status:

Has the child received further immunisation since enrolment?  Yes  No

If yes, attach a copy of the child’s immunisation status  copy attached

Second Review of immunisation status:

Has the child received further immunisation  Yes  No

If yes, attach a copy of the child’s immunisation status  copy attached

Review Date: ___ /___ /___ Review Date:___ /___ /___ Review Date:___ /___ /___ Child’s Confidential Record checked/updated by the educator/staff:

Anaphylaxis:
Parent provided with a copy of the Anaphylaxis Management Guidelines Date ___ /___/ ___
Anaphylaxis Management Plan and RMCP attachedDate ___ /___/ ___
Asthma:
Parent provided witha copy of the Asthma Management Guidelines Date ___ /___/ ___
Completed Asthma Action Plan and RMCP attached Date ___ /___/ ___
Epilepsy:
Parent provided with a copy of the Epilepsy Management Guidelines Date ___ /___/ ___
Completed Epilepsy Action Plan and RMCP attachedDate ___ /___ /___
Diabetes:
Parent provided witha copy of the Diabetes Management Guidelines Date ___ /___/ ___
Completed Diabetes Action Plan and RMCP attached Date ___ /___/ ___
Allergies:
Parent provided witha copy of the Allergy Management Guidelines Date ___ /___/ ___
Parent provided withaCity of Casey Allergy Management Plan Date ___ /___/ ___
Completed City of Casey Allergy Management Planand RMCP attached: Date ___ /___/___
DietaryRestrictions:
Completed Dietary Restrictions form attached: Date ___ /___ /___

Educator/staff full name: ______