HEALTHY LIFESTYLES
LEISURE SERVICESCrèche Enrolment Form
Privacy Statement
The information requested by Council on this form may constitute personal information under the Privacy and Personal Information Protection Act 1998. Council is allowed to collect the information from you to consider this matter. Supplying this information is voluntary. However if you cannot or do not wish to provide the information, we may not be able to consider the matter. If you need further details, please contact the Privacy Officer, Campbelltown City Council, corner Queen and Broughton Streets, Campbelltown.
Child’s Surname: / Child’s Name:
Street Address:
Suburb: / Postcode:
D.O.B: / Age: / Sex: / Male / Female
Parent / Guardian’s Name:
Phone: / Mobile:
Email:
Emergency Contact Details
The emergency contacts listed on this form will be contacted in the case of an emergency if the parent/guardian cannot be contacted. The emergency contacts listed on this form are the only people who can collect the listed child if the parent / guardian cannot collect them. All emergency contacts must be over 16 years of age. At least one emergency contact is required.
Emergency Contact 1 / Full Name:
Address: / Phone:
Mobile: / Relationship to child:
Emergency Contact 2 / Full Name:
Address: / Phone:
Mobile: / Relationship to child:
I hereby certify that I am willing for my son/daughter/ward whose particulars appear above, to attend Campbelltown Leisure Services activities and programs. In doing so, I guarantee and agree to hold Campbelltown City Council, its officers, employees and agents, including coaches and representatives of Campbelltown City Council and all other sporting representatives indemnified against all actions, claims, costs, losses, expenses and damages (including the costs of defending or settling any action or claim) which might hereinafter be made by or on behalf of my said son/daughter/ward or by myself or any other person for or in respect of any injury or loss sustained by him/her from any cause whatsoever, while he/she is taking part in activities that may be programmed.
I have read and understood the policies in relation to the program I am attending and agree to abide by and follow these policies. I give permission for a staff member to obtain the services of any ambulance or doctor if the need arises and agree to pay all charges and fees involved. I also agree to allow Campbelltown Leisure Services to use any photos obtained for promotional purposes.
Parent/Guardian Signature / Date: / /
Parent/guardian to complete the section below
Does your child:
Have any current physical injuries? / Yes No
If yes, describe the nature of the injury
Take any medication? / Yes No
If yes, list medication
Wear a Medic Alert Bracelet? / Yes No
If yes, provide further details / Number / Information
Carry an asthmatic inhaler? / Yes No
If yes, does he/she need to use the inhaler before/during exercise / Yes No
Have a history of any of the following:
Past / Present / Past / Present
Heart Trouble / Back or Associated Pain
High/low Blood Pressure / Spinal Abnormalities
Arthritis/Rheumatism / Ligament Laxity
Stress Incontinence / Other
Respiratory Ailments
Special Needs
Please provide description of any other medical condition, sensory or intellectual disabilities:
Changing Nappies
I hereby allow Campbelltown City Council staff to change my child’s wet nappy / Yes No
I hereby allow Campbelltown City Council staff to change my child’s soiled nappy / Yes No
I would prefer the Council’s staff to contact me to change my child’s nappy / Yes No
I agree to suppling all necessary, supplies, including nappy, wipes and cream / Yes No
Parent/Guardian Signature / Date: / /
Photography Agreement
I hereby allow photographs of my child be taken for the purpose of displaying in the Crèche and related marketing material / Yes No
Parent / Guardian Signature / Date: / /
DATAAND DOCUMENT CONTROL
Health Lifestyles
DocSet: 3656745 / Revised Date: 08/08/2016
Review Date: 30/09/2018 / Page 1
Version: 1