VAUCLUSE LITTLE SCHOOL

Long Day Care Centre

7

ENROLMENT FORM

Child Information

First Name
Last Name
Former names child is known by
Address
Child’s Sex / Male/female (please circle)
D.O.B
Child’s place in family
Language spoken
Ethnicity
Days attending / Mon Tue Wed Thurs Fri (please circle)
Start Date
Child’s CRN

Family Information

Mother / Father
Full Name
Other names parents are known by
D.O.B
CRN
Residential Address
Home Phone
Occupation/Work address
Work Phone
Mobile phone
Email address
Family Religion
Specific requirements for your religion

Emergency Contacts other then parents:

Name / Relationship to child / Address / Work phone / Home Phone / Mobile phone

Persons Authorised to Collect Child other then parents:

Name / Relationship to child / Address / Work phone / Home Phone / Mobile phone

Immunisations:Please bring a copy of your child’s immunization records, this can be obtained from www.my.gov.au website.

Birth certificate: Please supply a duly certified copy of your child’s birth certificate.

Emergency Permission

In signing this form I give Vaucluse Little School permission in an emergency to seek medical, hospital, dental or ambulance services on my behalf.

Parent’s Name: ______

Signed: ______Date: ______

Panadol Permission:In signing this form I give Vaucluse Little School permission to administer Panadol to my child in the recommended dose in the event of fever.I understand that I will be notified as soon as possible that my child has a fever and that Panadol may be given if appropriate and that I will make every attempt to collect my child as soon as practical.

Parent’s Name: ______

Signed: ______Date: ______

Medical History

Name of family doctor: ______Phone: () ______

Address: ______Postcode: ______

Medicare number (emergency use only): ______

Name of family dentist: ______Phone: () ______

Address: ______Postcode: ______

Ambulance Cover yes/no Private Health Cover yes/no

Health Card yes/no Health fund ______

List any intolerance/allergies or additional needs (e.g. physical, emotional, and behavioural) ______

______

Please list any medical information (asthma, convulsions, ear, tonsil, respiratory problems, and speech therapy)

______

Childhood diseases/previous illnesses ______

______

Has your child been hospitalised ______Length of stay ______

Child’s reaction ______

Medication is your child taking any medication? If so please specify ______

______

Are their any known side effects from this medication? ______

All medication MUST be handed personally to a staff member (never to be left in your child’s bag) and MUST be in the original container

NOTE: Please approach a staff member if your child needs medication to fill out medication form.

About your Child

Does your child sleep throughout the day? Yes/no (please circle) Time required ______

Does your child require a bottle? Yes/no (please circle) Formula or cows milk (please circle)

Time required ______

Is your child toilet training? Yes/no

Can your child use the toilet (please circle): Yes with Help No

Please list words that have meaning for you child: ______

Does your child feed her/himself at home: Yes with Help No

Has your child had any experience in care prior to coming to our centre? (Family day care, baby sitters, other childcare centre’s or preschool etc)______

______

Does your child get upset when left with other people? ______

Does your child have any fears/phobia, or has had any traumas (e.g. spider, dogs, thunder etc) ______

______

Please give any further information that may assist us in caring for your child: ______

______


What areas would you like to assist our centre in? Have you as a parent, time to volunteer at the centre? Some ideas are:

-  Excursions - cooking days - story reading

-  Parent meetings - feedback - open days

-  Educational days - child activities - fundraising

If you would like to be involved in any of these activities please circle, or if you have any suggestions or talents. Please feel free to note them down for us. ______

______

Family History

Marital Status of Parents ______

If separated does the other parent have contact to the child/ren? ______

What are the arrangements? ______

Are there any Court orders affecting the residency of the child/ren? ______

Details of any court orders ______

Note: Copies are required for our files, to enable court orders to be enforced

Child’s Siblings (bothers and sisters) Date of birth

1. ______

2. ______

3. ______

4. ______

Other people living at home Relationship to child

1. ______

2. ______

Parent contract and authorisation

1. I have read the parent handbook and I agree to abide by the centre policies and procedures

2. We would also like in writing an agreement from you regarding payment of fees. Please read the following and indicate where applicable.

I/we ______(name) understand that it is the centre’s policy that fees are paid to a nil balance monthly.

I/we agree to pay my/our fees for ______(child) on a monthly basis, and understand that if this is not done that care can be postponed/cancelled for my/our child/ren until the account is paid in full. I/we understand if fees are not paid, my account and details will be passed on to a debt collection agency.

3. I will notify the Family Assistance Office (FAO) and the centre regarding family circumstances changing.

4. I authorise the centre to contact my emergency contacts, if I am unable to be contacted. I give the centre consent to seek emergency medical assistance via ambulance if necessary to the nearest hospital, doctor or dentist along with administration of emergency medication, e.g. asthma medication, Panadol, epi-pen etc. I will take responsibility for any associated costs.

5. I will give four weeks (28 days) written notice for the cancellation of care.

6. I give permission for staff to apply appropriate nappy creams and powders on my child if they are in nappies. (Yes/no)

7. I give permission for sunscreen to be applied to my child for outdoor play. (Yes/no)

8. I give permission for the centre to take photos of my child and display them within the centre. (Yes/no)

9. I give permission for my child to participate in community promotion and advertising e.g. photographs, newspapers, television. (Yes/no)

10. I give the centre permission to video tape my child, which may be used at parent events. (Yes/no)

Signature: ______Date: ______

CREDIT CARD PAYMENT SLIP

Please Circle VISA MASTERCARD BANKCARD

Card Number______Expiry Date______

Card Verify Code______(3 digit code found on the back of the card)

Name______Signature______Date______

I ______give permission to Vaucluse Little School to debit my

credit card each month for the amount of $______, for the payment of my

child______childcare centre fees.

Contact Email: ______

I understand that this amount will be deducted on a monthly basis and if changes are required the Centre will inform me, and if there are any changes to my details or card information I will immediately inform the centre.

Are you claiming CCB (CHILDCARE BENEFIT): YES or NO (Please Circle)

Are you claiming CCR (CHILD CARE REBATE): YES or NO (Please Circle)

Are your payments being made to the CENTRE or DIRECTLY to your own bank account.

(Please Circle)

3 Russell St., Vaucluse NSW 2030 PH: 9337 4014