Goonawarra Neighbourhood HousePlaygroup Registration Form 2016

Parent / Carer Details

Parent or Carer Name
Relationship to child / Birthday:
Partner’s Name
Email Address
Contact Address
Phone Numbers / Home: / Mobile:
Aboriginal/Torres Strait Islander (please circle) / Country of Birth/Cultural Identity______/ Language Spoken at Home______
Emergency Contact
Name & relationship
Phone Number/s / Daytime: / Mobile:

Child/renattending playgroup

Surname / First name / Sex
M/F / Date of
Birth / Allergies / medical conditions of children attending playgroup
(please attach sheet if more space required)
1
2
3
If your child/renhas an allergy or a medical condition please discuss your management plan with the playgroup facilitator so that any incident can be responded to appropriately.
Discussed with Playgroup Facilitator Yes/No Date:______
Signed:
Playgroup Facilitator:______Parent/Carer:______

Immunisation Information

Is your child/ren’s Immunisation up to date? Yes/No
Has your child/ren attended their most recent MCH Age and Stage Visits Yes/No
No Jab No Play Legislation 2016 requires that we obtain a copy of your child/ren’s birth certificate, immunisation record & proof of address. (Privacy Legislation will be applied the information provided)
School Readiness
Is your 3 year old child enrolled to attend 4 year old kindergarten the following year? / Yes/No (please circle)
Is your 4 year old child attending 4 year old kindergarten? / Yes/No (please circle)
Playgroup Commencement Date and Session day/s and Time/s

Please tell us why you chose our playgroup and how you heard about us:

Have you attended Goonawarra Neighbourhood House Playgroup before?Yes / No

PRIVACY

Privacy Statement: The primary purpose of collecting this information is to enable to the Goonawarra Neighbourhood House Playgroup to adequately care for your child. All information regarding children is sensitive information within the terms of the national privacy principles under the Privacy Act. The information collected is used by the Goonawarra Neighbourhood House Playgroup for the aforementioned purpose and from time to time it may be given to the Manager at Goonawarra Neighbourhood House for the purpose of providing support.

By law, those attending playgroup are entitled to ask for and receive a copy of any personal information Goonawarra Neighbourhood House Playgroup holds about them. Should they wish to access this information, they can do so by forwarding a written request to one of the playgroup facilitator. This will be arranged within 14 days of receiving the request

INDEMNITY STATEMENT

I authorise the facilitator/manager in charge of the Goonawarra Neighbourhood Playgroup, where it is impracticable to communicate with me, to consent for my child to receive such medical or surgical treatment as may be deemed necessary.

I understand that my child/ren must be accompanied by an authorised, supervising adult who is responsible for my child/ren and their safety whilst they are attending the Goonawarra Neighbourhood House Playgroup.

“I agree to indemnify and hold harmless the Goonawarra Neighbourhood House Playgroup, and the Goonawarra Neighbourhood House against all claims, demands, suits and liability of whatever arises out of any injury to my child or myself whilst at playgroup.”

CONSENT

Special Permission

I give permission for my contact details to be included on the group list (for distribution to members of the playgroup). / Yes / No
I acknowledge that my child/ren’s photo may be taken by other parents / caregivers who are primarily taking photos of their children / Yes
I give permission for House Staff to photograph my child/ren within playgroup and use their photo to promote GNH Playgroup / Yes / No

I have read and understood the GNH Playgroup Information. I understand that the GNH Playgroup is run by the Goonawarra Neighbourhood House Incorporated. I agree to participate in and adhere to the Playgroup Procedures and Behaviour Policy. I have read the Privacy Statement and agree to Indemnity Statement.

Your Signature______Date ___/___/___

GNH Playgroup, 8 Gullane Drive, Sunbury 3429

MEMBERSHIP APPLICATION FORM

I______

(name in Block letters)

Of

Address______

______

Apply for Membership of the Goonawarra Neighbourhood House Association.

I support the aims and objectives of the Association and agree to abide by the House Rules.

Signature______

Date______

Approved by______

The nominated representative of the Goonawarra Neighbourhood House Incorporated Committee of Management.

PLAYGROUP ENROLMENT FORM 2016

2016

Page 1 of 4