Vacation Care Enrolment Form

GLADESVILLE OUT OF SCHOOL

HOURS INC.

VACATION CARE ENROLMENT FORM

All information contained in this enrolment form is regarded as confidential and shall only be reviewed by primary contact Educators.

Please read each section carefully before completing and signing.

SECTION 1: PARENT/GUARDIAN DETAILS

Parent/Guardian 1 Name:

Relationship to Child:
Date of Birth:
Address:
Home phone number:
Mobile Number:
Work phone number:
Are you an Australian resident: / YES / NO / (please circle)
Country of birth:
Language/s spoken at home:
Occupation:
Employer:
Work address:
Employment Status: / Full-time / Part-time / Casual / Not currently working
(please circle)
Email address:
CRN:
Parent/Guardian/Partner 2 Name:
Relationship to Child:
Date of Birth:
Address:
Home phone number:
Mobile Number:
Work phone number:
Are you an Australian resident: / YES / NO / (please circle)
Country of birth:
Language/s spoken at home:
Occupation:
Employer:
Work address:
Employment Status: / Full-time / Part-time / Casual / Not currently working
(please circle)
Email address:
CRN:

SECTION 2: CHILD CARE BENEFIT

Name of person claiming:

Date of Birth:
Will you be claiming CCB weekly or as a / YES NO (please circle)
lump sum payment? / If claiming as a lump sum, please complete a FAO 22 form
provided by the service.

For Child Care Benefit purposes, it is important to advise the service if you use any other service simultaneously.

SECTION 3: CHILD/REN’S DETAILS

Child 1 / Child 2 / Child 3
Child’s Full Name:
Male / Female:
Address of Child:
Date of birth:
Country of birth:
Child’s nationality:
Language/s spoken by
Child:
Families’ religion:
Is your Child of / No / No / No
Aboriginal or Torres / Yes, Aboriginal / Yes, Aboriginal / Yes, Aboriginal
Strait Islander origin? / Yes, Torres Strait / Yes, Torres Strait / Yes, Torres Strait
Islander / Islander / Islander
Child’s CRN
Days you wish your Child/ren to attend the service (please circle)
MONDAY
11.04.16 / TUESDAY
12.04.16 / WEDNESDAY
13.04.16 / THURSDAY
14.04.16 / FRIDAY
15.04.16
$57 / $60 / $73 / $45 / $83
MONDAY
18.04.16 / TUESDAY
19.04.16 / WEDNESDAY
20.04.16 / THURSDAY
21.04.16 / FRIDAY
22.04.16
$65 / $73 / $55 / $76 / $59

SECTION 4: CUSTODY INFORMATION

Are there any court orders, parenting orders or parenting plans in relation to your Child, or access to your Child?

YESNO (please circle) If YES please provide details:

______

______

______

NOTE: The service cannot enforce custody issues without a copy of the relevant Court Order beingprovided. Please discuss any custody issues with the Nominated Supervisor before enrolment.

SECTION 5: EMERGENCY CONTACTS

I/We hereby authorise the Educators of the service to contact the following people, if I cannot be contacted, in the case of an emergency.

Please supply at least 2 names, other than the Child/ren’s parents/guardians.

NAME / ADDRESS / MOBILE / HOME/WORK / RELATIONSHIP TO
PHONE / CHILD

NOTE: It is important that you inform the above people that you have included them as emergencycontacts and that they may be contacted in the case of an emergency, with your Child/ren or the service, and asked to collect your Child/ren when you cannot be contacted.

Authority to collect you Child/ren from the Service

I/We hereby authorise the service Educators to allow the following people to collect my Child/ren.

NAME / ADDRESS / MOBILE / HOME/WORK / RELATIONSHIP TO
PHONE / CHILD

NOTE: It is important that you inform the above people that they may be asked to show identification ontheir first few visits until the Educators become aware of whom they are. Only those people to whom you have given authority will be permitted to collect your Child/ren from the service.

SECTION 6: MEDICAL INFORMATION

Family’s Doctor’s name:______

Telephone number:______

Does your Child/ren have any allergies or/and health issues (including asthma or anaphylaxis)? YES NO (please circle)

If YES, Please provide Child/ren’s name and Date of Birth: ______

If YES please provide details, including a copy of a medical management plan annually, (required for asthma and anaphylaxis) or risk minimisation plan prepared by the Child’s doctor:

______

______

Does your Child/ren require regular medication? YES NO (please circle) If YES please provide details:

______

______

______

Is your family a member of a Private Health Fund? YES NO (please circle)

Name of Private Health Fund:______

Private Health Fund number:______

Family Medicare number:______

NOTE: Medication will only be administered in accordance with the service Administering MedicationPolicy that you will be provided with.

Immunisation

Has your Child/ren received the necessary immunisation for their age? YES NO (please circle)

If NO, please complete and attach an Immunisation Exemption Conscientious Objection form available from Medicare.

Medical Conditions/Additional Needs

Does your Child/ren have a medical condition or require additional assistance to meet their needs? YES NO (please circle)

If YES please provide details of the condition/needs they require assistance with:

______

______

______

SECTION 7: INDIVIDUAL INFORMATION

This information assists Educators in the daily care and education of your Child/ren.

Does your Child/ren have any dietary requirements other than allergies? YESNO (please circle)

If YES please provide details:

______

______

______

Is there anything else our Educators needs to know about your Child/ren? (E.g. cultural or religious requests, interests, dislikes, fears etc.)

______

______

______

NOTE: Educators will also talk individually to your Child/ren about their interests on a regular basis andincorporate these into the program and experiences on offer.

SECTION 8: AUTHORISATION AND APPROVAL (PERMISSION)

NOTE: Please read this section carefully. If you do not give your permission for any of the following, pleasecross it out and initial.

1. PERMISSION TO SEEK MEDICAL ASSISTANCE IN AN EMERGENCY

That in the case of an accident or other emergency resulting in the need for immediate medical attention, I/We hereby give permission for the Educators to take my Child/ren to a doctor or hospital to seek the following urgent treatments:

Medical

Dental

Hospital

Ambulance Service and transport of the Child by Ambulance

1. PERMISSION TO CARRY OUT APPROPRIATE FIRST AID TREATMENT IN AN EMERGENCY

That in the case of an accident or other emergency resulting in the need for immediate medical attention, I/We hereby give permission for the service to carry out appropriate first aid treatments.

1. PERMISSION FOR THE APPLICATION OF SUNSCREEN

I/We hereby give permission for Educators to apply sunscreen to my Child/ren before outdoor play activities.

4. PERMISSION FOR PHOTOGRAPHS/VIDEOS TO BE TAKEN

I/We hereby consent to my Child/ren being photographed/videoed while they are at the service or on an excursion.

NOTE: There are a number of reasons the service takes photographs/videos of the Children, including:

Providing visual documentation for families to see what their Child/ren does throughout the day To assist with evaluations of the program

To use as part of promotion and publicity for the service E.g. service website, emailing programs to families, etc

5. NOTIFICATION OF ARRIVAL AND DEPARTURE OF CHILDREN AT THE SERVICE

I/We agree to have my Child/ren signed in and out on the appropriate documentation on arrival and departure each day they attend the service.

6. CHILD ABSENCE

I/We agree to notify the service if my Child/ren is absent on a day they are booked in. If the parent/guardian fails to inform the service of their Child/ren’s absence they will incur a $5.00 non-cancellation fee per family.

1. PAYMENT OF FEES
2. BOND

Upon being offered a place at the service, parent(s) or guardian are required $50.00 security bond per family and $55.00 membership fee per family.

The bond secures your Child/ren’s placement at the service, and is refundable at the termination of your Child/ren’s place, provided that two weeks notice in writing is given. The bond may be used to cover and/or settle your final account.

Bond payments are payable to the service by cheque, money order or cash.

2. NOTICE OF DISCONTINUATION OF ATTENDANCE

When you wish to discontinue and terminate your child care place at the service you are required to provide two (2) weeks written notice to the Director/Nominated Supervisor or you are liable to pay the equivalent of two weeks child care fees to the service.

3. ABSENCES FROM THE CHILD CARE CENTRE

Fees are NOT payable for bank/public holidays and pupil free days if those days fall on a day that your Child is booked into the service. Fees are NOT payable for cancellation days provided you give two (2) weeks’ notice in writing is given.

4. SERVICE CLOSURE

No fee is charged while the service is closed over the Christmas period.

5. LATE FEE

Should Children be present after the 6:00pm closing time, a late of $5.00 per minute will apply.

6. PAYMENT OF FEES

As per the services Family Handbook, fees are to be paid in advance on the first day of the

Child/ren’s weekly attendance. Fortnightly fees are payable to the service by Direct Debit. I/We understand that funds must be made available from the nominated account in accordance to the Fee Direct Debit Timetable dates which is sent out to families for each term. I/We understand that my Child/ren’s place at the service may be terminated if fees are not up to date, and that I/We may be liable for any additional costs incurred in recovery of outstanding fees. I/We understand it is the parent/guardians responsibility to notify the service if there are any changes with the nominated account the service Direct Debits from.

7. COSTS OF DEBT RECOVERY

I/We ______and ______

expressly agree that I/We am liable for any Recovery Costs including administrative fees, debt recovery fees, Solicitor Fees and disbursements incurred by Gladesville Out of School Hours Inc. as a result of my failure to pay the fees and charges for the service provided within the strict terms of payment with 14 days specified in this agreement. I/We accept that I/We may also be charged an additional fee for interest at the statutory rate recoverable in the appropriate Court at the time prevailing however I/We am aware that costs incurred through Court action against me will be limited to the fees recoverable under the State Legislation for legal cost recovery.

8. DISCLAIMER/INFORMED CONSENT

I/We hereby acknowledge that:

I/We have read and understand the services procedures, conditions and policies contained in this enrolment record and policy manual, which forms part of this agreement (and which may be charged by notice from time to time by the service at it’s sole discretion) (Policies and Procedures).

The Policies and Procedures incorporate any relevant statuory obligations imposed on the service and have been put in place to protect my Child/ren.

I/We must strictly comply with the Policies and Procedures at all times.

The information provided in this enrolment record is to best of my knowledge correct. I/We will inform the service immediately in writing if there are any changes to the information provided by me in this enrolment record (Notice of Change).

When caring for my Child/ren the service will rely on the information provided by me in this enrolment record, and any Notice of Change and any other instructions/information (of any nature whatsoever) I/We give to the service.

I/We am totally responsible for the accuracy of the Information and my compliance with the Policies and Procedures.

I/We am totally responsible for the sustainability and actions of any person/s whom I/We authorise to visit, deliver, and or collect my Child/ren to/from the service or any other place. Subject to any applicable Australian Consumer Law, the Sales of Goods Act 1923 (NSW) or any other applicable law which cannot be excluded I/we will indemnify the service its employee’s or any of its authorised person/s from any loss, damage, claim or expense of any nature whatsoever incurred by my Child/ren, by the parents/guardians or any third party inconnection with any act or omission by me and/or us and or Other Person/s failing to comply with any Policies and Procedures and or due to the inaccuracy of the Information and or the acts or omissions of the Other Person/s.

SECTION 9: MEMBERSHIP

The service is an Incorporated Association and as such, by enrolling my Child/ren in the service I/We agree to be bound by the rules of the Association for the period of my Children’s enrolment. I/We understand that as a member of the Incorporated Association, I/We are representatives of my Child/ren’s family is entitled to voting rights at any Annual General Meeting held by the service and that I/We may be nominated (with consent) for a position on the Parent Management Committee at the Annual General Meeting.

The person/s nominated for member representation is/are: ______

(parent/guardian 1 name) and ______ (parent/guardian 2 name).

SECTION 10: DECLARATION

I/We hereby declare that to the best of my knowledge, the information provided in this enrolment form is true and accurate.

Parent/Guardian 1 Name:______

Signature:______

Date:______

Parent/Guardian 2 Name:______

Signature:______

Date:______