Henschke Primary School Hall, 103 Fernleigh Road, Wagga Wagga NSW 2650
PO Box 7218 Wagga Wagga NSW 2650
Ph: 0459 467 864
ABN: 52 191 791 853
Enrolment Form
Strictly Confidential
Child’s Family Name:Child’s Given Names:
Section 1: Family Details
Parent / Guardian 1 Name:Home Phone: / Mobile Ph:
Postcode:
Will you be claiming Child Care Benefit? YES NO
If YES, please provide the information required, below.
Address: Street:
Suburb:
Email address: (Used for billing)
Centrelink Customer Details:
First Name:
Customer CRN:
______- ______- ______
Relationship to Child: Mother
Work Details:
Work Ph:
Other Parent / Guardian: / Middle Name:
Date of Birth:
_____ / _____ / ______
Father Other
Employer:
Work Address: / Last Name:
Gender: F M
Please specify:
Name: / Relationship to Child: / Work Ph: / Mobile Ph:
Name: / Relationship to Child: / Work Ph: / Mobile Ph:
Child’s Details
Gender: M F Date of Birth: _____ / _____ / ______Child’s CRN: ______- ______- ______
Class: School:
Indicate with whom the child lives Both parents ( ) Mother ( ) Father ( ) Guardian ( )
Any Custody/ Court Orders? Yes ( ) No ( ) (Where applicable provide Court Order) Y/ N
If appropriate, court orders sighted, copy made. Signed: ______Date: ______
Coordinator
Indicate Family Status Both Parents in Work/Study ( ) One Parent in Work/Study ( )
Number of children in care at other services:
Section 2: Medical Information
Has your child received the necessary Immunisation for their age? YES NO
If YES, a copy of the child’s Immunisation History Statement is attached.
If NO, a completed Immunisation Exemption Conscientious Objection Form, available from Medicare, is attached.
Any medical Conditions:
Yes ( ) No ( )
Eg Asthma, Migraines, eczema
Asthma Management Plan Yes ( ) No ( ) / Provide Details and in the case of Asthma, please supply a Management Plan from your Medical Practitioner:
Any Prescribed Medicines:
Yes ( ) No ( ) / Provide Details and Possible Side Effects:
Any Allergic Reaction:
Yes ( ) No ( )
Any requirement for Epipen:
Yes ( ) No ( )
Copy of Anaphylaxis Management Plan
Yes ( ) No ( ) / Provide details and briefly describe severity of condition:
(eg. Food: peanut, fish Products: suncreen, soaps)
Doctor: / Ph: / Addr:
Dentist: / Ph: / Addr:
Medicare No: / ______ / ______
Authorisation:
I/we give permission to administer First Aid on my/our child if deemed necessary, without obtaining my permission. Should at any time the staff consider that my/our child requires medical, dental or hospital treatment, I/we hereby consent to you obtaining such treatment with all possible speed, at my/our expense. I/we understand that all attempts will be made to contact me/us; however treatment will not be delayed in the event I/we cannot be contacted. I/we understand that relevant information on this form will be passed on to hospital/medical staff if required.
Signed: ______Date: ______
Emergency Contacts
The following individuals have permission to collect my child from HOOSHC, and can be contacted in the event that I am unable to be contacted.
- Name:
______/ Address:
Home Ph: / Mobile Ph:
Work Ph:
- Name:
______/ Address:
Home Ph: / Mobile Ph:
Work Ph:
- Name:
______/ Address:
Home Ph: / Mobile Ph:
Work Ph:
Section 3: Bookings
Priority of Booking
Permanent Child Care places are allocated to families based on the priority of access listed below in accordance with Government guidelines. Appropriate measures shall be taken to ensure families with the greatest need are able to access child care. Please indicate(√)using the boxes, below your family’scurrent situation:
Priority 1: A child at risk
Priority 2: A child whose parent or parents satisfy the work/training/study test under section 14 of the Tax System (Family Assistance) Act 1999
Priority 3: Any other child
Mon am ( ) / Tues am ( ) / Wed am ( ) / Thurs am ( ) / Fri am ( )
Mon pm ( ) / Tues pm ( ) / Wed pm ( ) / Thurs pm ( ) / Fri pm ( )
Casual Only ( )
Please indicate preferred days of attendance (AM- 7.00am to 9.00am, PM 3.18pm to 6.00pm)
Child’s expected starting date at the Service: ______/ ______/ ______
HOOSHC Registration/Maintenance Fee:
One off. $32.50 per family, payable upon first registering with HOOSHC.
-Cheque payable to “Henschke Out of School Hours Care Inc”; or
-EFT to Henschke Out of School Hours Care Inc
BSB: 112 879 (St George Account)
Account No: 410793031
With child’ssurname and initial as reference
Fees:
Fees are payable weekly or fortnightly, by arrangement. Invoices will be emailed to families on a weekly basis. Fees are to be paid a minimum of 2 weeks in advance.
Ezidebit is the preferred method of payment, but cash, cheque or direct deposit are accepted. Cheques can be made out to Henschke Out of School Hours Care Incorporated.
Before School Care:$10.50 per session (Permanent Bookings) $14.50 (Casual Bookings)
After School Care:$23.00 per session (Permanent Bookings) $27.00 per session (Casual Bookings)
Vacation Care:$37.50 per day
Pupil Free Days:$37.50 per day
If my account is in advance on ceasing the service with HOOSCH, I/we give permission for any money payable back to me, to be donated to HOOSHC after a period of time where three attempts to notify me of this money owing was unsuccessful.
Signed: ______Date: ______
Section 4: General Information
Cultural / Interests
The following provides staff information about your child and their interests
Any special needs:Please complete Enrolment form B which can be obtained from the Coordinator
Yes ( ) No ( ) / Provide Details:
Form Provided ( )
Any Cultural, religious or social factors for staff to be aware of:
Yes ( ) No ( ) / Provide Details:
Languages spoken at home other than English:
Yes ( ) No ( ) / Provide Details:
Indoor Interests: / Outdoor Interests:
Any other information to make your child’s time at HOOSHC as safe and enjoyable as possible?
(Specific things that may upset your child eg thunderstorms)
HOOSHC Management
The following requires authorisation for your child to participate at HOOSHC
HOOSHC staff are able to provide sunscreen to my child / Yes ( ) No ( )My child us able to watch G and PG movies
(understand that staff will only select movies that are appropriate for primary school aged children) / Yes ( ) No ( )
HOOSHC are able to take and display photos of my child within HOOSHC and in any relevant publication / Yes ( ) No ( )
HOOSHC staff are able to administer children’s Panadol or children’s Nurofen in the prescribed dosage as required / Yes ( ) No ( )
PLEASE NOTE: If any of the information provided on this Enrolment Form changes, I understand it is my responsibility as a parent to inform the HOOSHC Co-ordinator and provide an updated Enrolment Form.
Signed: ______Date: ______
Please return your completeform to the Coordinator of Henschke Out of School Hours Care Inc.
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