LLLC Enrolment Form, 2017

This form confirms booking of a space at the LLLC for a minimum 1 term contract. If you have any questions, please ensure you contact us before submitting this enrolment form.

CHILD’S DETAILS

Surname ______Given name ______

Male ( ) Female ( )DOB ___ / ___ / ___ Child’s age at entry______

Address______

______Postcode ______

Medicare number ______Expiry date ___ / ___ / ___ Child’s number on card ______

Private health insurer ______Number ______

Ambulance subscriber Yes/No Number ______

Child’s Doctor’s name ______Phone ______

Child’s first language? ______

PARENT / GUARDIAN DETAILS

Surname ______Given name ______

Relationship to child______

Phone (h) ______Phone (w) ______Phone (m)______

Email ______

Surname ______Givenname ______

Relationship to child______

Phone (h) ______Phone (w) ______Phone (m)______

Email ______

Are there any accommodation, intervention or custody orders concerning the child? Yes / No

If yes, please provide details

______

CHILD'S MEDICAL HISTORY

LLLC 2016Language and Literacy Learning Centre2017 Enrolment FormV1.0

Asthma* / ⃝ Yes ⃝ No / Psychiatric conditions / ⃝ Yes ⃝ No
Ever been hospitalised for asthma / ⃝ Yes ⃝ No / Begun menstruation / ⃝ Yes ⃝ No
Diabetes** / ⃝ Yes ⃝ No / Sleepwalking / ⃝ Yes ⃝ No
Epilepsy/seizures*** / ⃝ Yes ⃝ No / Bedwetting / ⃝ Yes ⃝ No
Fainting/dizzy spells / ⃝ Yes ⃝ No / Travel sickness / ⃝ Yes ⃝ No
Heart problems / ⃝ Yes ⃝ No / Uses glasses/contacts / ⃝ Yes ⃝ No
Migraines / ⃝ Yes ⃝ No / Uses hearing aids / ⃝ Yes ⃝ No
Ever been hospitalized / ⃝ Yes ⃝ No / Allergies (see below) / ⃝ Yes ⃝ No
Major surgeries / ⃝ Yes ⃝ No / Other (explain below) / ⃝ Yes ⃝ No
Please explain further (please add additional sheets if necessary):
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*Must complete and attach ASTHMA MANAGEMENT PLAN form
** Must have review with medical team prior to attending the Centre and create a "DIABETES AT LLC" MANAGEMENT PLAN (this may differ significantly from your home and school management plan)
***please describe type, frequency, length and management of seizures, and date of last seizure

LLLC 2016Language and Literacy Learning Centre2017 Enrolment FormV1.0

Immunisations are up to date ⃝ Yes ⃝ No(Please provide a copy of your child's immunisation schedule)

If no, why? ______

Date of last Tetanus injection ______

COMPLEX BEHAVIOURS

Has your child ever been diagnosed as having complex behaviours ⃝ Yes ⃝ No

If you answered yes, please help us understand the nature of the behaviour.

ADHD - inattentiveness⃝ Yes ⃝ No

ADHD - hyperactive/ impulsive ⃝ Yes ⃝ No

Oppositional defiance / conduct disorder ⃝ Yes ⃝ No

Mood disorders / anxiety ⃝ Yes ⃝ No

Autism spectrum disorder ⃝ Yes ⃝ NoType of ASD ______

Does your child have an intellectual disability? ⃝ Yes ⃝ NoIntellectual Age______

Does your child have a physical disability? ⃝ Yes ⃝ No

How will this affect their time at camp, and how should we be of assistance?

______

ALLERGIES

Does your child have any allergies? ⃝ Yes ⃝ No

Has your child ever been hospitalized for an allergic reaction?⃝ Yes ⃝ No

Does your child carry an adrenaline injector (eg EPIPEN) for an allergy? ⃝ Yes ⃝ No

Has your child been diagnosed as anaphylactic? ⃝ Yes ⃝ No

If yes, please ensure your child attends camp with a recent action plan.

Please list all allergies, symptoms and required treatment below:

Allergies / Reaction/Severity / Treatment

LLLC 2016Language and Literacy Learning Centre2017 Enrolment FormV1.0

OTHER INFORMATION:

Dietary Requirements:

Vegetarian ⃝ Vegan ⃝ Kosher ⃝ Halal ⃝ Gluten Free ⃝ Diabetic ⃝ Other (please describe)

(Please indicate whether these selections are a choice or diagnosed.)

______

Does your child have any cultural beliefs or practices we should be aware of? ⃝ Yes ⃝ No

If so please describe:

______

Signature ______Name ______Date ___ / ___ / ___

Consent for photography / video:

I consent to The Language and Literacy Learning Centre, 2017 using photographs or videos of my child/ren in any legal way that it thinks fit, including publication or dissemination in any medium. I acknowledge that The Language and Literacy Learning Centre,2017 is the owner of any intellectual property in such images and any material (including promotional material) created using the photographs or videos. I waive any moral rights that I might have in my child/rens name/s, his/her/their images, photographs, or any captions relating to the photographs or videos. I release and forever discharge The Language and Literacy Learning Centre, 2017 and its servants and agents against all proceedings, claims and demands by me in respect of any matter or thing, including loss or damage of any kind sustained or likely to be sustained by me as a result of, arising out of, or in connection with, any use by The Language and Literacy Learning Centre, 2017 of the photographs or videos and any captions relating to them. I acknowledge that I have no right to require payment for, or participate in, any proceeds arising out of the use of the photographs or videos. All inappropriate photography including photos taken in bedrooms, close-ups of sensitive body areas and photos that in any way demean the child ARE NOT PERMITTED.

Signature ______Name ______Date ___ / ___ / ___

ESSENTAIL items to include with your application

  • Copy of your child’s birth certificate
  • Copy of child’s immunisation schedule
  • Any other relevant documentation in regards to child’s learning difficulty and/or medical conditions.

LLLC 2016Language and Literacy Learning Centre2017 Enrolment FormV1.0