Vacation Care
Postal Address: PO Box 468, Annerley 4103
Phone: 3270 6451 Fax: 3392 6249 ABN: 28 728 322 186
Email:
Booking Form
Please return this form and all other relevant documents back to UnitingCare Community - Vacation Care by Monday 8th of September 2014. Bookings received after this date will be subject to staff availability. All information fields must be completed for your booking to be processed.Please note that there are limited places available and places will be allocated in line with Priority of Access guidelines as stated in the Vacation Care- Parent Handbook.
1 Inclusion Support Form last revised 20.08.10
Vacation Care
Postal Address: PO Box 468, Annerley 4103
Phone: 3270 6451 Fax: 3392 6249 ABN: 28 728 322 186
Email:
Section 1 – Child Details(Children to attend service)
Child #1 Name / DOB:Medication required on program?
Yes No / Gastrostomy Feed
Yes No
Please complete plan / Allergies
Yes No
Anaphylaxis
Yes No / Epilepsy
Yes No
Child #2 Name
Medication required on program?
Yes No / Gastrostomy Feed
Yes No
Please complete plan / Allergies
Yes No
Anaphylaxis
Yes No / Epilepsy
Yes No
1 Inclusion Support Form last revised 20.08.10
Vacation Care
Postal Address: PO Box 468, Annerley 4103
Phone: 3270 6451 Fax: 3392 6249 ABN: 28 728 322 186
Email:
Section 2 – Contact Details
Parents NamePostal Address
(if changed)
Post Code
Email Address
Home Phone / Work Phone / Mobile
Emergency Contact – To be contacted if parent is unable to be reached
Name / Relationship
Home Phone / Work Phone / Mobile
1 Inclusion Support Form last revised 20.08.10
Vacation Care
Postal Address: PO Box 468, Annerley 4103
Phone: 3270 6451 Fax: 3392 6249 ABN: 28 728 322 186
Email:
Section 3 – Payment Options
Invoices to be sent to / Parent/Carer / Support organisationIf a support organisation is to be invoiced for fees, the person responsible for payment/contact person must fill in the follow section confirming payment, before this booking can be formalised. No booking can be made without organisation approval.
Organisation Name
Attention to / Contact Phone Number
Postal Address
Email Address
1 Inclusion Support Form last revised 20.08.10
Vacation Care
Postal Address: PO Box 468, Annerley 4103
Phone: 3270 6451 Fax: 3392 6249 ABN: 28 728 322 186
Email:
Do you have any other children in care? / Yes / NoIf yes, how many?
Section 4 – Administration
The following information needs to be accurate and up to date to correctly calculate your Child Care Benefit and Fee Reduction.
Customer Reference Numbers (CRN) can be obtained from the Family Assistance Officer on 136 150.
The following information needs to be accurate and up to date to correctly calculate your Child Care Benefit and Fee Reduction. No application will be taken without this information.
Parents Full NameParent CRN / D.O.B
Child #1 Full Name
Child #1 CRN / D.O.B
Child #2 Full Name
Child #2 CRN / D.O.B
Do you have any other children in care? / Yes / No
If yes, how many?
1 Inclusion Support Form last revised 20.08.10
Vacation Care
Postal Address: PO Box 468, Annerley 4103
Phone: 3270 6451 Fax: 3392 6249 ABN: 28 728 322 186
Email:
Section 5 – Booking Options
Please indicate preferred serviceBeenleigh / Mt Gravatt
Mt Ommaney / Mitchelton
Permanent Bookings Sep 2014 – Apr 2015
Monday / Tuesday / Wednesday / Thursday / Friday
Sep/Oct 2014 booking only
22nd Sep / 23rd Sep / 24th Sep / 25th Sep / 26th Sep
29th Sep / 30th Sep / 1st Oct / 2nd Oct / 3rd Oct
In order to manage staff costs more effectively please advise times that you will be picking up and dropping off your son/daughter.
Estimated drop off time:Estimated pick up time:
Section 6 – Permissions
I give consent to my child’s photograph being taken. I understand that the photos will not be used by UCC for any promotional purposes unless prior written consent is obtained. Photos will be used for purpose of documenting my child’s Vacation Care experience. / I give consentSign:
Date: / I do not give consent.
Sign:
Date:
Sharing of Information- I give consent for UCC to contact the following external parties to share information and obtain information regarding my child’s support needs in order to work collaboratively to provide my child with the best care possible. Documentation may include medical plans and behaviour support plans.
School Name
Contact Person / Contact Phone Number
Postal Address
Email Address
Sharing of Information- I give consent for UCC to contact the following external parties to share information and obtain information regarding my child’s support needs in order to work collaboratively to provide my child with the best care possible:
Name of Organisation
Contact Person / Contact Phone Number
Postal Address
Email Address
Sharing of Information- I give consent for UCC to contact the following external parties to share information and obtain information regarding my child’s support needs in order to work collaboratively to provide my child with the best care possible:
Name or organisation
Contact Person / Contact Phone Number
Postal Address
Email Address
Due to increasing demands for placements this Vacation Care, Staff Availability and following the priority of access, you may not receive all of the days requested.
Please note that you will be placed on a waiting list for any last minute cancellations.
Section 7 – Terms and Conditions
I agree to all terms and conditions for my child to attend UnitingCare Community Vacation Care and understand that Vacation Care will do their best to meet my requested booking needs. I agree to and understand the following:If my child is unwell they will not be able to attend Vacation Care, this is to minimise the spread of germs and illness. If my child becomes sick throughout the day I may be contacted to pick up my child. If my child is sick I understand that I may need to obtain a doctors clearance before they are able to return to Vacation Care.
My child will have all their personal requirements with them each day including: Morning/Afternoon Tea, Lunch, minimum 2 changes of clothes, hat, any personal care item e.g. nappies, medications and medical procedure equipment (if applicable).
UnitingCare Community Vacation Care is Allergy Aware and requires your assistance to be Nut Free, please consider the many clients at Vacation Care whom have severe allergic reactions to nuts.
Vacation Care operates from 8am-5pm and I understand that I must drop off and pick up my child between these times.
I am aware of my responsibly to collect my child if an unsafe situation arises, my child is ill or injured or my child’s behaviour has become unsafe and more assistance is required than staff ratios allow.
I am aware that cancellations or date changes can be made up to one week out from the first day of Vacation Care and any after that date will incur a cancellation fee of $20 per day.
I will notify UCC Vacation Care if my child will be absent from the program and understand that I will be charged the full fee for all bookings confirmed.
I will notify UCC Vacation Care if my child will be absent from the program and understand that I will be charged the full fee for all bookings confirmed.
I will notify the Administration Team on 3270 6451 (ask for Vacation Care) of any changes to my child’s health care needs as they arise. I understand that I am responsible for the payment of my Vacation Care account within fourteen days of invoice issued.
I understand that all profiles and medical information will need to be completed correctly and must be up to date before UCC Vacation Care can confirm any booking. The information collected by UCC will be used to improve supports to young people accessing the program and therefore it is essential that this information be updated at a minimum of 12 monthly or as changes occur.
I understand my child may not be approved for all days requested and that UCC approves applications on the basis or risk assessment as well as according to priority of access as outlined by the Family Assistance Act and the Service Agreement with the funding body.
Signature of Parent/Carer / Date
Name (please print full name)
1 Inclusion Support Form last revised 20.08.10