MIRANDA VACATION CARE ENROLMENT FORM
Terms & ConditionsFee Payments
§ In applying for enrolment, I hereby acknowledge that I am wholly responsible for all fees payable to Sutherland Shire Council, in respect to my child/ren being in care.
§ I understand that any fees paid are not refundable or transferable.
§ I am aware that bookings are subject to availability and the early bird rate will not apply after the enrolment closing date. Please Refer to the current Schedule of Fees & Charges on the Council’s Website.
§ I am aware that I am required to complete either my credit card details or direct debit details on the attached form.
§ I am aware that I am liable to pay for the days and excursions requested on this form (subject to availability) and I cannot cancel or request an exchange of days.
§ I am aware that I can add days and make payment at that time
Injury or Loss to Person or Personal Property
§ I understand that whilst every care and precaution will be taken, Sutherland Council and its staff are not responsible for any injury, damage or loss to my child or their possessions whilst at the Centre or on an excursion.
Child Care Benefit & Child Care Rebate
§ Any request for a CCB backdate can only be done up to 30 days from the end of the Vacation Care period.
§ I understand that I am responsible for registering for Child Care Benefit and Child Care Rebate.
§ I acknowledge that if there is no Child Care Benefit or Child Care Rebate approval at the time of my booking I am liable to pay full fees.
Privacy And Storage Of Information
The personal information that Council is collecting from you is for the purposes of the Privacy and Personal Information Protection Act 1998 (“the Act”).
The information you have supplied will be stored at Council while your child is attending care and electronically for Child Care Benefit purposes. This information will then be stored in Council archives for up to 7 years.
The intended recipients of the personal information are:
§ Authorised Officers within Sutherland Shire Council
§ A person otherwise authorised by law to inspect the records.
Council is collecting this information for the purpose of maintaining accurate child-care information and parental contact details. In addition, Council may use this information for time to time in order to contact you to inform you of updated children’s services information.
Booking Conditions
§ Payment will be processed or charged by close of business the day your booking is received
§ Attendance will be refused if parent arrives at service without making payment prior
§ Bookings received after the closing date will be charged the daily fee rate
§ If your enrolment form is not completed your booking will not be processed until a completed enrolment form is received.
Excursions & Transport
§ I understand that excursions may be cancelled due to low numbers and I will be credited back the excursion cost
§ I understand that due to numbers and staffing my child may be transported to and from another centre if they are not attending an excursion, and I will be notified of this at the centre.
Has your child been immunised in accordance with Department of health guidelines?
Please supply an updated immunisation statement if your child falls into one of the following categories:
§ Child is new to the service
§ Child has been immunised since last supplied immunisation statement
I have agreed to enrol my child/ren
in the Sutherland Council Vacation Care Program. / (Names of children)
I have read the agree to the abovementioned Terms and Conditions
Relationship to child/ren:
Print Name: / Date:
Email Address:
You must complete all the sections below:
Parent/Guardian 1 / Relationship to Child/renFirst Name / Surname
Home Phone No / Work Phone No
Mobile Phone No / Date of Birth
Address
Occupation
Country of Birth
Parent’s CRN
Parent/Guardian 2 / Relationship to Child/ren
First Name / Surname
Home Phone No / Work Phone No
Mobile Phone No / Date of Birth
Address
Occupation
Country of Birth
Parent’s CRN
Medicare Number:
Emergency Contact / Contact 1 / Contact 2
First Name
Surname
Home Phone No
Work Phone No
Mobile Phone No
Relationship To Child
Please tick which permissions you give each contact person
To collect child/ren / To collect child/ren
To authorise medication for child / To authorise medication for child
To authorise excursions for child / To authorise excursions for child
CULTURAL BACKGROUND
What is the primary language used in your child/ren’s home?
What is the cultural background of your child/ren?
What is the cultural background of you and your partner?
Are there any religious or cultural requirements relating to your child/ren's upbringing that you would like us to honour in caring for your child/ren?
Are you or any of the children listed on this form Aboriginal or Torres Strait Islander background?
Aboriginal
Torres Strait Islander
Aboriginal and Torres Strait Islander
Neither
Unknown
Decline to advise
WHERE DID YOU HEAR ABOUT THIS SERVICE?
Our Shire
Internet
Have Used Before
Word Of Mouth
School Newsletter
Library
Other (Please Specify)
REASON CARE REQUIRED (X ONE only)
At Risk / Referral (e.g. DoCS Referred)
Working / Studying / Maternity Leave / Returning to work / Looking for Work
Respite Care - Not Working and Not Looking for Work
Are there any Court Orders or Custody Arrangements Relating to your Child/ren?
If Yes a certified copy needs to be supplied prior to the start of care
Child 1 / Child 2First Name
Surname
Date Of Birth
Gender
Child’s School
Allergies
Special Needs or Medical Conditions
Country of Birth
Child’s CRN
Child 3 / Child 4
First Name
Surname
Date Of Birth
Gender
Child’s School
Allergies
Special Needs or Medical Conditions
Country of Birth
Child’s CRN
Authorisations
§ Adhesive Dressing Tape
§ Plastic Bag For Amputation
§ Non-Adhesive Dressing Pad
§ Sterile Eye Pad
§ Conforming Gauze Bandage
§ Conforming Gauze Bandage
§ Disposable Latex Gloves / § Thermo Accident Blanket
§ Safety Pins - Assorted
§ Scissors - Sharp/Blunt Splinter Forceps
§ Sterile Eyewash
§ Antiseptic Swabs
§ Triangular Bandage
§ Band-Aids/Elastoplasts / § Sterile Wound Dressing
§ First Aid Guide Forehead Thermometer
§ Rapaid First Aid Spray
§ Rapaid Itch Relief Sachet
§ Disposable Resuscitation Face Shield
§ First Aid Tool Box (11090)
Authorisation / Details
Cancer Council Sunscreen 30+ / Active: - Octyl Methoxycinamate 60mg/g
- Butyl Methoxydibenzoylmethane 20mg/g
Other: - Phenoxyethanol 3mg/g
- Hydroxybenzoate 4mg/g
- Methylbenzylidene Camphor 30mg/g
Rid Cream Repellent / Active: - 160b LN, N-diethyl m Tuoluamide (DEET)
- 20g/1 N-Octyl Dicycloheptene Dicarboximide
- 10g/1 Di-N-Propylisocinchomeronate
- 1g/1 Tricolsan
Panadol Colour-Free / - 5ml contains 120 mg paracetamol
- Free from asprin, sugar and alcohol
Ventolin - (in the event of a suspect Asthma Attack) / - 100mg Salbutamol
- HFA - 134a propellant
Photography & Video / Use
For developmental, educational, publication or communication, purposes at the Centre
Student Documentation / Use
For TAFE and / or University Students to observe and document information about my child for the purpose of Early Childhood Studies. I am aware that all documentation will remain confidential and only first names will be used.
I give permission for all of the above items to be used on my child/ren
Children’s Names:
I give permission for the above items to be used on my child/ren EXCEPT the items listed below
Child’s Name / Items to not be used
PERMISSION FOR MEDICAL TREATMENT & AMBULANCE SERVICE / Initial
Yes / No
I authorise staff at the service to seek emergency treatment for my child from a registered medical practitioner including medical, hospital, dental and ambulance service (including ambulance transportation) should this be considered necessary.
Completed By: / Date:
Monday 29th June 2015 - Friday 10th July 2015
Please complete the sections below:
BOOKING OF DAY/S: (Please cross in the appropriate box the days you require)
r Denotes Compulsory excursion/activity days J Denotes Optional excursion/activity days
WEEK 1
ChildsName / Age / Monday / Tuesday / Wednesday / Thursday / Friday
29th June / 30th June / 1st July / 2nd July / 3rd July
r / J / J / J / r J
1)
2)
3)
4)
Week 1 / Description / No. Children / Excursion Fee / Total Payable
29/06/15 / Bob Turner Wildlife (All Ages Compulsory) / X / $14.00 / = / $
30/06/15 / AMF bowling (10-14 yrs Optional) / X / $23.00 / = / $
01/07/15 / ANZ Stadium Tour (All Ages Optional) / X / $30.00 / = / $
02/07/15 / Movies @ Miranda (All Ages Optional) / X / $27.00 / = / $
03/07/15 / Pedal Go Karts (5-12 yrs Compulsory) / X / $12.00 / = / $
03/07/15 / Flip Out (10-14 yrs Optional) / X / $30.00 / = / $
Total Fee for Excursions Week 1 = $
** The Early Bird Rate is $50.00 plus excursion / activity costs on bookings received before the closing date **
** The Daily Rate is $55.00 plus excursion / activity costs on bookings received after the closing date **
BOOKING OF DAY/S: (Please cross in the appropriate box the days you require)
r Denotes Compulsory excursion/activity days J Denotes Optional excursion/activity days
WEEK 2
ChildsName / Age / Monday / Tuesday / Wednesday / Thursday / Friday
6th July / 7th July / 8th July / 9th July / 10th July
J / r J / J / J / r
1)
2)
3)
4)
Week 2 / Description / No. Children / Excursion Fee / Total Payable
06/07/15 / Shopping Extravaganza (10-14 yrs Optional) / X / $5.00 / = / $
07/07/15 / Mic Conway Music (5-12 yrs Compulsory) / X / $9.00 / = / $
07/07/15 / Lunch @ Sizzler (10-14 yrs Optional) / X / $23.00 / = / $
08/07/15 / Picnic @ Como Pleasure Grounds (10-14 yrs Optional) / X / $5.00 / = / $
09/07/15 / NAIDOC @ Gunnamatta (All Ages Optional) / X / $15.00 / = / $
10/07/15 / Jumping Castle (All Ages Compulsory) / X / $14.00 / = / $
Total Fee for Excursions Week 2 = $
** The Early Bird Rate is $50.00 plus excursion / activity costs on bookings received before the closing date **
** The Daily Rate is $55.00 plus excursion / activity costs on bookings received after the closing date **
PAYMENT METHODS
CREDIT CARD - a 0.8% merchant fee is applicable on all credit card payments - See details below
Cardholder’s Name:Card Type: / Visa / MasterCard / American Express
Card No:
Expiry Date: / /
Payments will automatically be deducted and an email sent advising the amount to be deducted
DIRECT DEBIT - this option is only available in advance of care date
Please use my existing Direct Debit set up for Vacation Care
Please use set up a Direct Debit for Vacation Care using the details below
Financial Institution:Branch:
Name on account:
BSB Number:
Account Number:
Note - Name of account is not the type of account, i.e. Savings, Home loan; it is the name the account is under, i.e. Mr John Citizen, Mrs J. D. Citizen.
Payments will automatically be deducted and an email sent advising the amount to be deducted
Direct Debit Conditions
I understand that if my Direct Debit is dishonoured by the above Institution, I will incur a fee. (see current Schedule of Fees & Charges)
I understand if my account details change I must inform Sutherland Shire Council Children’s Services in writing.
Completed By: / Date:This page is to be returned to Children’s Services