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MERCY CHILD DAY CARE SERVICES

ENROLMENT FORM

CHILD DETAILS

First Name ______Date of Birth ______CRN: ______

Surname ______Gender (M/F) ______

Residential address ______Postcode ______Phone ______

Religion ______

School Attended ______Year ______

Is your child of Aboriginal or Torres Strait Islander Origin? . No Aboriginal Torres Strait Islander

Does your child have any special needs/considerations? Yes No Details ______

CARE REQUIREMENTS

Commencement date: ______

Please tick what days you require:

Monday / Tuesday / Wednesday / Thursday / Friday

______

Education and Care Regulatory Unit requires that you provide us with a copy of your Child’s Immunisation Record and a copy of their Birth Certificate – they cannot start until this information is provided.

PARENT/GUARDIAN

First Name (Mother) ______Date of Birth ______CRN ______

Surname ______

Residential Address ______

Postcode ______Phone/Home ______Mobile ______

Phone/Work ______

Occupation ______Company ______

Work Address ______

Email Address ______

Home / Working > 15 hours / Looking for work / Studying or Training / Disability or Disabled Carer(please circle)

PARENT/GUARDIAN

First Name (Father) ______Date of Birth ______CRN ______

Surname ______

Residential Address ______

Postcode ______Phone/Home ______Mobile ______

Phone/Work ______

Occupation ______Company ______

Work Address ______

Email Address ______

Home / Working > 15 hours / Looking for work / Studying or Training / Disability or Disabled Carer(please circle)

CHILD’S HEALTH DETAILS

Has your child been diagnosed with a disability? YesNo

Disability ______Date Diagnosed ______

Does your child have Asthma? Yes No Triggers ______

(Please provide an Asthma Action Plan from your doctor before commencement)

Is your child Anaphylactic? Yes No Triggers/allergens______

______

(Please provide an Anaphylaxis Action Plan from your doctor before commencement)

Other Allergies______

Fits Yes No Details______

Skin Problems Yes No Details______

Eyesight Problems Yes No Details______

Other Chronic Health Problems Yes No Details______

Previous Illness or Operations ______

Family Doctor ______

Address ______

Phone______Ambulance Fund # ______

Medicare # ______Health Fund # ______

OTHER DETAILS

Which parent has been assessed for CCB ______

Is this parent liable for the payment of fees? Yes No

Cultural Background ______

Language spoken at home ______

Any other special needs (i.e. Cultural/Religious or Dietary ______

______

DETAILS OF GUARDIANSHIP/CUSTODY AND TERMS OF ANY SPECIFIC ACCESS PROVISIONS (Please attach current court orders)

______

EMERGENCY CONTACTS (OTHER THAN PARENT) who are authorized to collect and drop off children

First NameLast Name Relationship to Child Address Telephone

1 ______

2 ______

3 ______

FEE DECLARATION

I have read and agree to the conditions outlined in the Fee Policy and that I am responsible for the payment of this account. If I leave Mercy Early Learning Centre with a debt my details will be forwarded onto a debt collection agency, I understand that I will be liable for all debt collection fees.

Parent Signature ______

Authorisation – I hereby authorise the CertifiedSupervisor or her agent at the Centre to administer medication or seek medical attention including arranging transportin the case of an emergency.

Parent Signature ______

Authorisation – I hereby give permission for my Educators to take photos of my child to be used within the centre and in Children’s portfolios which may be sent home with families. Please advise in writing if you prefer your child not be photographed while at the centre.

Parent Signature ______

Authorisation – I hereby give permission for my child to have sunscreen applied at the centre. If I do not wish the centre to apply their sunscreen I will supply my own.

Parent Signature ______

I have received and read a copy of the Parent Policy Handbook and agree to all administration policies contained therein.

Parent Signature ______Date ______