PUCKAPUNYAL AND DISTRICT NEIGHBOURHOOD CENTRE

ENROLMENT FORMS FOR CHILDREN UNDER THE AGE OF 182018

The information collected in this enrolment form is to enable PDNC to operate programs and ensure that we meet State and Federal legislation. The PDNC will ensure that the information given is used for the purpose of ensuring the health and safety of the children in the programs and will not be used for any other purpose.

ALL CHILDREN UNDER THE AGE OF 18 MUST HAVE COMPLETED ENROLMENT FORMS TO PARTICIPATE IN THE PDNC PROGRAMS AND PARENTS MUST HAVE A VAILD MEMBERSHIP AT THE PDNC. IT IS THE PARENTS/GUARDIANS RESPONSIBILITY TO SUPPLY ANY ASTHMA OR ANAPHLYAXIS MANAGEMENT PLANS PRIOR TO ATTENDING ANY PDNC PROGRAMS.

CHILD #1 DETAILS:

NAME
DATE OF BIRTH
ADDRESS
MOBILE #

CHILD #2 DETAILS:

NAME
DATE OF BIRTH
ADDRESS
MOBILE #

CHILD #3 DETAILS:

NAME
DATE OF BIRTH
ADDRESS
MOBILE #

PARENT / GUARDIAN #1 DETAILS

NAME
ADDRESS
MOBILE #
ALTERNATE #

PARENT / GUARDIAN #2 DETAILS

NAME
ADDRESS
MOBILE #
ALTERNATE #

In the case of an accident or emergency, all efforts will be made to contact the parents/guardians listed. If contact cannot be made, please supply alternative emergency contacts.

ALTERNATE EMERGENCY CONTACT #1 DETAILS

NAME
ADDRESS
MOBILE #
ALTERNATE #
RELATIONSHIP TO CHILD

ALTERNATE EMERGENCY CONTACT #2 DETAILS

NAME
ADDRESS
MOBILE #
ALTERNATE #
RELATIONSHIP TO CHILD

Please give details of any allergies or other relevant medical conditions and needs of the child. Please give details of any management procedures to be followed with respect to that allergy, condition or need.

**Attach further information if required.

ALLERGY / MEDICAL CONDITION / MANAGEMENT PROCEDURE

As Parent / Guardian, it is a requirement of the PDNC that you supply your child/rens management plans for Asthma and/or Anaphylaxis. It is your responsibility to notify PDNC of any medical conditions, which are of a life threatening nature. The PDNC will endeavour, wherever possible to manage and minimise risks associated with either asthma or Anaphylaxis.

It is PDNC policy that all children are required to bring any medication along to any programs they attend. Children are responsible for their own medication. Any child with Anaphylaxis must bring their Epipen kits if they wish to attend programs. Children are to inform monitor/s of any medication required to be taken.

AS PARENT/GUARDIAN, WE ARE AWARE THAT THE PDNC IS ONLY RESPONSIBLE FOR OUR CHILD/REN WHILST WITHIN THE CONFINES OF THE PDNC PROGRAMS AND BUILDING THEY OPERATE FROM. CHILD/REN MUST COMPLY WITH THE RULES AND FOLLOW INSTRUCTION FROM THE PROGRAM MONITOR/S OR THEY WILL BE BANNED FROM PARTICIPATING IN THE PROGRAM FOR A PERIOD OF TIME SET BY THE COMMITTEE OF MANAGEMENT.

OFFENSIVE LANGUAGE, INTIMATE CONTACT,FIGHTING, HARRASSMENT AND/OR BULLYING WILL NOT BE TOLERATED.

By signing below, you acknowledge all the rules set out by the PDNC and agree to follow those rules.

…………………………………………..……………………………………………………………………………………………..

Child #1Child #2Child #3

As Parent/Guardian you acknowledge you are allowing your child/ren to attend programs run by volunteers of the PDNC. These volunteers are there to monitor children and enforce the rules of the PDNC whilst the program is being run. Monitor/s do not take responsibility for any child/ren outside the set program timings.

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Signed Parent / Guardian #1Signed Parent / Guardian #2