SCHOOL AGED CARE ENROLMENT FORM

YARRAWONGACOLLEGE P-12

OUTSIDE SCHOOL HOURS CARE

Ph # 0418 175 237

PARENT/GUARDIAN 1

FULL NAME :

CUSTOMERREF. NUMBER

(Of parent receiving CCB)

NATIONALITY: AUST □ OTHER______

RELAT/SHIP TO CHILDREN :

/ / / / MAIN
LANGUAGE ______

DATE OF BIRTH :

HOME/POSTAL ADDRESS :

HOME PHONE :

MOBILE PHONE :

EMAIL ADDRESS :

WORK DETAILS

PHONE NUMBER :

ADDRESS :

EMPLOYER/ : F/T or P/T ?

OCCUPATION

DOES CHILD/CHILDREN RESIDE WITH THIS PARENT/GUARDIAN YES or No ?

PARENT/GUARDIAN 2

FULL NAME :

NATIONALITY: AUST □ OTHER ______

RELAT/SHIP TO CHILDREN :

/ / / / MAIN
LANGUAGE ______

DATE OF BIRTH :

HOME/POSTAL ADDRESS :

HOME PHONE :

MOBILE PHONE :

EMAIL ADDRESS :

WORK DETAILS

PHONE NUMBER :

ADDRESS : F/T OR P/T ?

EMPLOYER/OCCUPATION:

DOES CHILD/CHILDREN RESIDE WITH THIS PARENT/GUARDIAN YES or NO ?

SECTION 2 – CHILD DETAILS
CHILD 1
SURNAME:
MALE □ FEMALE □
SCHOOL:
/ / /
YES □ NO □ / IMMUNISATIONS UP TO DATE? YES □ NO □
YES □ NO □

FIRST NAME :

CHILD’SREF. NUMBER:

GENDER :

GRADE :

DATE OF BIRTH :

ABORIGINAL OR TSI

DESCENT :

PERMISSION FOR PHOTOS:

►DO YOU HAVE YOUR CHILDS HEALTH RECORD BOOK? OR A COPY OF THEIR IMMUNIZATION CERTIFICATE YES □ NO □

PLEASE PROVIDE A COPY OR HEALTH BOOK FOR STAFF TO SIGHT. SIGHTED OR COPY GIVEN YES □ NO □

►ALLERGIES/ILLNESSES: – PLEASE ATTACH RELEVANT DETAILS AND ACTION PLANS. E.G. ANAPHYLAXIS

►MEDICATIONS :______

►SPECIAL CONSIDERATIONS (BEHAVIOURAL, SPEECH, FEARS, DISABILITIES, RELIGION, CULTURAL, DIETARY RESTRICTIONS) ______

______

►DO YOU OR A GUARDIAN RECEIVE CARERS ALLOWANCE FOR SUCH SPECIAL NEEDS? YES □ NO □

IF YES, PLEASE ATTACH A PHOTOCOPY OF THE CHILD’S :-

1. CURRENT HEALTH CARECARDAND

2. RELEVANT DOCTORS DIAGNOSIS LETTER.

CHILD 2
SURNAME:
MALE □ FEMALE □
SCHOOL:
/ / /
YES □ NO □ / IMMUNIZATIONS UP TO DATE? YES □ NO □
YES □ NO □

FIRST NAME :

CHILD’SREF. NUMBER :

GENDER :

GRADE :

DATE OF BIRTH :

ABORIGINAL OR TSI

DESCENT :

PERMISSION FOR PHOTOS:

►DO YOU HAVE YOUR CHILDS HEALTH RECORD BOOK? OR A COPY OF THEIR IMMUNIZATION CERTIFICATE YES □ NO□

PLEASE PROVIDE A COPY OR HEALTH BOOK FOR STAFF TO SIGHT. SIGHTED OR COPY GIVENYES □ NO □

►ALLERGIES/ILLNESSES: – PLEASE ATTACH RELEVANT DETAILS AND ACTION PLANS. Eg. ANAPHYLAXIS

►MEDICATIONS : ______

►SPECIAL CONSIDERATIONS (BEHAVIOURAL, SPEECH, FEARS, DISABILITIES, RELIGION, CULTURAL, DIETARY RESTRICTIONS) ______

______

►DO YOU OR A GUARDIAN RECEIVE CARERS ALLOWANCEFOR SUCH SPECIAL NEEDS? YES □ NO □

IF YES, PLEASE ATTACH A PHOTOCOPY OF THE CHILD’S :-

1. CURRENT HEALTH CARECARD AND2. RELEVANT DOCTORS DIAGNOSIS LETTER.

CHILD 3
SURNAME:
MALE □ FEMALE □
SCHOOL:
/ / /
YES □ NO □ / IMMUNIZATIONS UP TO DATE? YES □ NO □
YES □ NO □

FIRST NAME :

CHILD’SREF. NUMBER :

GENDER :

GRADE :

DATE OF BIRTH :

ABORIGINAL OR TSI :

DESCENT

PERMISSION FOR PHOTOS:

►DO YOU HAVE YOUR CHILDS HEALTH RECORD BOOK? OR A COPY OF THEIR IMMUNIZATION CERTIFICATE YES □ NO □

PLEASE PROVIDE A COPY OR HEALTH BOOK FOR STAFF TO SIGHT. SIGHTED OR COPY GIVEN YES □ NO □

►ALLERGIES/ILLNESSES: – PLEASE ATTACH RELEVANT DETAILS AND ACTION PLANS. E.G. ANAPHYLAXIS

►MEDICATIONS: ______

►SPECIAL CONSIDERATIONS: (BEHAVIOURAL, SPEECH, FEARS, DISABILITIES, RELIGION, CULTURAL, DIETARY RESTRICTIONS)______

______

►DO YOU OR A GUARDIAN RECEIVE CARERS ALLOWANCE FOR SUCH SPECIAL NEEDS? YES □ NO □

IF YES, PLEASE ATTACH A PHOTOCOPY OF THE CHILD’S :-

1. CURRENT HEALTH CARECARDAND

2. RELEVANT DOCTORS DIAGNOSIS LETTER.

IF YOUR CHILD IS STARTING PREP, DO YOU HAVE A “TRANSITION TO SCHOOL STAEMENT” FOR YOUR CHILD/ CHILDREN? YES □ NO □

ARE YOU WILLING TO SHARE THIS INFORMATION WITH OUR OSHC SERVICE (FOR PROGRAMMING AND PLANNING PURPOSES)? YES □ NO □

EMERGENCY CONTACTS
PLEASE INCLUDE AT LEAST 2 CONTACTS

CONTACT 1

MOB. PH : / WORK PH :
YES □ NO □ / PERMISSION TO PICK UP YES □ NO □

FULL NAME :

RELAT/SHIP TO CHILD :

HOME PHONE :

ADDRESS ::

NOTIFY IN AN EMERGENCY

CONTACT 2

MOB. PH : / WORK PH :
YES □ NO □ / PERMISSION TO PICK UP : YES □ NO □

FULL NAME :

RELAT/SHIP TO CHILD :

HOME PHONE :

ADDRESS :

NOTIFY IN AN EMERGENCY

CONTACT 3

MOB. PH : / WORK PH :
YES □ NO □ / PERMISSION TO PICK UP YES □ NO □

FULL NAME :

RELAT/SHIP TO CHILD :

HOME PHONE :

ADDRESS :

NOTIFY IN AN EMERGENCY

CUSTODY ISSUES

ARE THERE ANY COURT ORDERS IN RELATION TO YOUR CHILD/CHILDREN? YES □ NO □

IF YES, PLEASE ATTACH A COPY OF THIS DOCUMENTATION.

______

______

______

FAMILY MEDICAL DETAILS
YES □ NO □ NUMBER :

FAMILY DOCTOR

MEDICAL CENTRE

PH. NUMBER

MEDICARE NUMBER

AMBULANCE MEMBER

CHILD CARE BENEFIT DETAILS

CONTACT THE FAMILY ASSISTANCE OFFICE ON 13 61 50 TO REGISTER YOUR CHILD/CHILDREN FOR THE CHILD CARE BENEFIT (CCB).

1. PLEASE OBTAIN CHILD’S/CHILDRENS REFERENCE NUMBERS/S AND RECORD IN THEIR DETAILS SECTION

2. OBTAIN 1 PARENT’S REFERENCE NUMBER – THE PARENT WHO IS REGISTERING FOR CCB - AND RECORD IN THEIR DETAILS SECTION.

N.B WITHOUT THESES REFERENCE NUMBERS FULL FEES WILL NEED TO BE CHARGED!

DO YOU HAVE OTHER CHILDREN IN CHILDCARE (LONG DAY CARE/FAMILY DAY CARE) ?

IF YES, HOW MANY?

PARENT DECLARATIONS

I AGREE TO PAY MY FEES ON A WEEKLY/FORTNIGHTLY BASISAND TO KEEP STAFF INFORMED OF ANY CHANGES TO CARE REQUIRED.

I AGREE WITH THE CONDITIONS IN THE PARENT HANDBOOK.

I AUTHORISE THE OSHC COORDINATOR IN THE EVENT OF ANY UNFORSEEN ACCIDENT OR ILLNESS, TO OBTAIN SUCH MEDICAL ASSISTANCE AS DEEMED NECESSARY AND AGREE TO MEET ANY EXPENSES ATTACHED TO SUCH TREATMENT.

I ACCEPT FULL RESPONSIBILITY FOR MY CHILD’S BELONGINGS WHILST ATTENDING THE OSHC PROGRAM.

I FULLY UNDERSTAND THAT IF MY CHILD CONTINUOUSLY DISPLAYS INAPPROPRIATE AND OR UNACCEPTABLE BEHAVIOUR AT THE PROGRAM AFTER GUIDANCE PROCEDURES HAVE BEEN FOLLOWED, I WILL BE NOTIFIED AND MY CHILD MAY BE REMOVED FROM THE PROGRAM.

I WILL INFORM PROGRAM STAFF OF ANY ABSENCE OF CARE OF MY CHILD/CHILDREN.

I ACKNOWLEDGE THAT MY CHILD WILL NOT ATTEND THE PROGRAM IF SUFFERING FROM AN INFECTIOUS CONTAGIOUSDISEASE OR IS GENERALLY UNWELL AND NOT ABLE TO PARTICIPATE IN OSHC ACTIVITIES.

IN THE EVENT THAT MY CHILD IS INJURED OR BECOMES UNWELL DURING THE PROGAM, EITHER AN AUTHORISED PERSON OR MYSELF SHALL COLLECT MY CHILD AS SOON AS POSSIBLE.

I UNDERSTAND THAT THE ENROLMENT DETAILS ARE PRIVATE AND CONFIDENTIAL..

PARENT /GUARDIAN SIGNATURE ______DATE ______

YARRAWONGACOLLEGE P-12 OSHC STORES AND USES PERSONAL INFORMATION FOR THE PURPOSE OF ADMINISTRATTION. THE INFORMATION WILL NOT BE DISCLOSED TO THIRD PARTIES WITHOUT YOUR CONSENT, EXCEPT TO MEET GOVERNMENT, LEGAL OR OTHER REGULATORY AUTHORITY REQUIREMENTS.

REFERENCES : Child Care Act 2002, Child Care Regulation 2009, Freedom of Information Act 1992, Privacy Act 1988, YarrawongaCollege P-12 Employee Code of Conduct, OSHC Confidentiality Policy