Please ensure you complete and return ALL forms

ROAD TRIPPINWinter 2015 APPLICATION FORM

The child and parent Customer Reference Number (CRN), parent name and parent date of birth are used by the Family Assistance Office to allocate the child benefit to eligible families. For eligible families to receive this benefit please take care to ensure this page is filled out correctly, that the correct NAME, ADDRESS, DOB, and CRN numbers for each person are entered, and that you are registered with Centrelink to receive this benefit.

CHILDS DETAILS
Family Name ______First Name ______
Residential Address______
Telephone – Home ______Sex  Female Male
Is your child of Aboriginal, Torres Strait Island or Australian South Sea Island Origin? Yes No
Which Primary School does your child attend?
Child’s CRN ______
D.O.B ______/______/______
Name of Parent/Guardian 1:
Surname ______First Name ______
Residential Address ______
Work Phone______Mobile ______Home______
Email Address ______
In what Shire or City do you work? ______
Mother’s CRN ______
D.O.B ______/______/______
Name of Parent/Guardian 1:
Surname ______First Name ______
Residential Address ______
Work Phone ______Mobile ______Home______
Email Address ______
In what Shire or City do you work? ______
Father’s CRN ______
D.O.B ______/______/______

Emergency Contact Other Than Parents:

  1. Name ______Relationship ______Phone______
  1. Name______Relationship ______Phone ______
  1. Name______Relationship ______Phone ______
List a person other than the parents who is authorised by the parent/guardian to collect your child?
  1. Name ______Relationship ______Phone______
  1. Name ______Relationship ______Phone______
Custody Of Child
Are there any custody issues at the moment  Yes  No
If yes, please attach a copy of the order and provide details of guardianship, custody and terns of any specific custody or access provision.
______

Medical Information

Doctors Name ______Phone ______
Medicare No ______
Private Health Insurance Company and Number ______
Ambulance Subscription Yes No
Allergies / Illnesses:  Yes  No
Does your child have known allergies ?______ Yes  No
If yes, please provide a current Allergy Action Plan signed by their Medical Practioner. Attached Yes  No If your child is taking medication which is from the pharmacy, staff cannot administer it without doctors permission letter explaining dosage and child’s name e.g.( Panadol, clarantyne etc )
Does your child require regular medication? ______ Yes  No
If Yes, and staff are required to administer medication, you will be required to complete a Medication form.
Has your child been diagnosed as at risk of Anaphylaxis?  Yes  No
If Yes, please provide a copy of their Anaphylaxis Management Plan signed by their Medical Practitioner.
Attached Anaphylaxis Management Plan  Yes  No
Has your child been diagnosed with Asthma?  Yes  No
If Yes, please provide a copy of their Asthma Management Plan. Attached  Yes  No
Has your child been diagnosed with Diabetes?  Yes  No
If Yes, please provide a copy of their Diabetes Management Plan. Attached  Yes  No
Does your child have a developmental delay or disability including intellectual, sensory or physical impairment?  Yes No
If yes, please discuss this with the Youth Advocate/Coordinator.
In the case of an emergency do you consent to a blood transfusion  Yes  No
Do you give permission for staff to apply sunscreen to your child? Yes  No

Privacy Statement

YMCA Whittlesea acknowledges and respects privacy of individuals. The information that is collected on this document form is for the purposes of processing your enrolment in YMCA Whittlesea’s children’s services, providing you with updated information and assisting us to improve our services. The personal information collected is of the parent/guardians and the child enrolled in the program. By completing this form YMCA Whittlesea accepts that the parent/guardian of the child have consented for this information to be collected. The intended recipients of this information are YMCA Whittlesea, its staff and relevant Government authorities. You have the right to access and alter personal information concerning yourself or your child in accordance with the Commonwealth Privacy Act (Amended 2001) and YMCA WhittleseaPrivacy Policy.

Parent / guardian Terms and Conditions – children are to be signed out each day.
I understand and approve to the above application and in doing so agree that YMCA Whittlesea and its officers, leaders, staff and agents shall be released from, and shall not incur, any responsibility or liability for any accident or injury to the applicant or for any damage to or loss of property of the applicant. I further authorise you to obtain medical/ambulance assistance in the case of an accident or an emergency involving the applicant and I agree to bear all costs thereby incurred. Furthermore, I give permission for my child/ren to leave the Centre to attend excursions for which they have enrolled and for other program activities.
Signed______Date ______

Payment canbe made at the YMCA Whittlesea Head Office in person at any time. If you have any questions regarding payment, we have provided confirmation and payment sessions that you can attend todiscuss with the Youth Advocate/Co-Ordinator or you can phone on 9407 6206. Thesession’s dates are on the brochure. Payment can be made by Cash, Eftpos and Credit Card.