Banyule Leisure Facility Management

Confidential Enrolment Form

Information Required by Children’s Services Regulations 2009

This form must be completed ON or BEFORE your first visit to the Creche facility.

Please contact the Creche Team Leader if you required assistance in completing this form.

Information about the Child

Child’s Full Name: ______

Child’s DOB: ______Male  Female 

Home Address: ______P/C: ______

Home Contact Number: ______

Email Address: ______

Language spoken at home:

Information about the Child’s Primary Caregiver who has Lawful Authority

Contact Person / Address / Relationship to Child / Contact Number

Doctors Contact Details

Doctors Name / Address of Surgery / Contact Number

Collection of Children from the Service (please provide 2)

In the event where the Primary Caregiver is unable to collect the child, due to an injury or accident within the premises, the following people have lawful authority to collect the child. These people must present identification upon collection of the child. ie. Licence identification, verbal or written from the parent on the day. Verbal authority will only be accepted in emergencies.

Contact Person / Address / Relationship to Child / Contact Number

Authority to photograph children at play

For centre displays YESNO

For publicity and promotion of the serviceYESNO

Health information

Does your child have any special needs? Yes No

If yes please provide details of any special needs and any management procedure to be followed with respect to the special need.

______

Anaphylaxis

Has your child been diagnosed at risk of anaphylaxis? Yes No

Does your child have an auto injection device (eg EpiPen®)? Yes No

Has the anaphylaxis medical management plan been provided to the service? Yes No

Has a risk management plan been completed by the service in consultation with you? Yes No

In the case of anaphylaxis you will by provided with a copy of the services anaphylaxis management policy. You will be required to provide the service with an individual medical management plan for your child signed by the medical practitioner who is treating your child. This will be attached to your child’s enrolment form.

More information can be found at www.education.vic.gov.au/anaphylaxis

Does your child have a child health record? Yes No

If yes, please provide to the service for sighting.

Child health record means a record that documents a child’s health and development assessments and immunisations.

Name and position of person at the children’s service who has sighted the child’s health record.

______

Court Orders relating to the Child

It is a legal requirement that the children’s service maintains a copy of any Custody or Access order, which affects a child or children within the service. These orders must be supplied for inclusion on your child’s record.

If yes please attach a copy of the court order.

Are there any Family Court Orders affecting the Custody of, or access to child/children? /  Yes /  No

Consent for Creche staff to seek Medical Treatment/Administer Medication

I understand that the staff within this service will act in my child’s best interests and notify me as soon as possible of any event that occurs within the service.

In the event where I cannot be contacted, I hereby authorise the service to seek the necessary Emergency, Hospital, Dental or Ambulance service treatment in the event of an illness or accident occurring to my child. (This will be at my expense, re.16(h).)

Declaration:

I the undersigned free the Banyule Leisure Facility Management staff from the responsibility of an accident or illness of myself or the enrolled participant, whilst being cared for in the service. I further authorise Banyule Leisure Facility Management to undertake/obtain any medical assistance that may be deemed necessary.

Council respects all personal and confidential information you give and will do everything possible to protect information from unauthorised access, loss or misuse. Information collected from you is used for the purpose of processing the application, to conduct research and customer satisfaction surveys so that we may better understand community need and can improve on our service delivery. Should you need to change or access your personal details, please contact the Ivanhoe Aquatic & Fitness Centre on (03)9490-7111, Olympic Leisure Centre on (03)9459-1193 or the Banyule Nets Stadium on (03)9455-8888.

I ______, understand that the information provided will be used in accordance with relevant legislation and declare that this information is correct to the best of my knowledge.

Signature: ______Date:______

BLFM / 09816 CRECHE updated rrent Enrolment Form.doc / InfoVision Ref: / Last Amended: 15/05/2019 / Page 1 of 1