EmailMe Form - 2022 Enrolment Form

North Balwyn Playcentre Incorporated

CHILD DETAILS

Child First Name *

Child Last Name? *

Name Child is Usually Called? *

Gender? *

Child's Address? *

Street Address City State / Province / Region Postal / Zip Code

Child's Date of Birth *

DD / MM / YYYY

Child's Country of Birth: *

Languages Spoken in the Home? *

Is the child of Aboriginal and/or Torres Strait Islander origin? *

PARENT 1 DETAILS:

****Please note that Parent one is also the claimant for Child Care Subsidy if applicable****

Parent 1 First Name *

Parent 1 Last Name *

Parent 1 Date of Birth *

DD / MM / YYYY

Parent 1 Country of Birth *

Parent 1 Primary Language *

Parent 1 Mobile Phone *

### - ### - ####

Parent 1 Home Phone (Please include area code)

### - ### - ####

Parent 1 Occupation *

Parent 1 Work Phone (Please Include Area code if landline)

### - ### - ####

Parent 1 Email *

Parent 1 Address *

Street Address City State / Province / Region Postal / Zip Code

PARENT 2 DETAILS

Parent 2 First Name *

Parent 2 Last Name *

Parent 2 Date of Birth *

DD / MM / YYYY

Parent 2 Country of Birth *

Parent 2 Primary Language *

Parent 2 Mobile Phone *

### - ### - ####

Parent 2 Home Phone (Please include area code)

### - ### - ####

Parent 2 Occupation *

Parent 2 Work Phone (Please Include Area code if landline)

### - ### - ####

Parent 2 Email *

Parent 2 Address *

Street Address City State / Province / Region Postal / Zip Code

CHILD'S LIVING ARRANGEMENTS

Who does the child live with? *

COURT ORDERS RELATING TO THE CHILD

Are there any court orders relating to the powers, duties, responsibilities or authorities of any person in relation to the child or access to the child? *

Please provide details of any court or tribunal orders, parenting orders or parenting plans relating to powers, duties, responsibilities or authorities of any person in relation to the child or access to the child below

Please upload a copy of any court order here:

Please describe details of any other court or tribunal orders relating to the child's residence or the child's contact with a parent or other person.

Other Persons with Authorisation:(AUTHORISED NOMINEES)

An Authorised Nominee means a person who has

1. any person who is to be notified of an emergency involving the child if any parent of the child cannot be immediately contacted. This person is also authorised to collect the child from the service if any such emergency exists. (AT LEAST ONE PERSON MUST BE NOMINATED FOR THIS)

2. been given permission by a parent or family member to collect the child from the education and care service.

3. any person who is authorised to consent to medical treatment of, or to authorise administration of medication to, the child; and

4. any person who is authorised to authorise an educator to take the child outside the education and care service premises;

Please indicate below which permission types are granted to each person. Please note that this is a mandatory requirement for enrolment.

AUTHORISED NOMINEES

AUTHORISED NOMINEE 1:

Nominee 1 First Name *

Nominee 1 Last Name *

Address *

Street Address City State / Province / Region Postal / Zip Code

Phone *

### - ### - ####

Relationship to Child *

Please indicate below which authorisations apply to this nominee. Please select as many as apply: *

1. This person is to be notified of an emergency involving the child if a parent of the child cannot be immediately contacted and is authorised to Collect the child from the service if needed(at least one nominee must be authorised in this category)

2. Authorised to Collect the child from the service

3. Authorised to consent to medical treatment of, or to authorise administration of medication to, the child

4. Authorised to authorise an educator to take the child outside the education and care service premises

AUTHORISED NOMINEE 2:

Nominee 2 First Name

Nominee 2 Last Name

Address

Street Address City State / Province / Region Postal / Zip Code

Phone

### - ### - ####

Relationship to Child

Please indicate below which authorisations apply to this nominee. Please select as many as apply:

1. This person is to be notified of an emergency involving the child if a parent of the child cannot be immediately contacted and is authorised to Collect the child from the service if needed(at least one nominee must be authorised in this category)

2. Authorised to Collect the child from the service

3. Authorised to consent to medical treatment of, or to authorise administration of medication to, the child

4. Authorised to authorise an educator to take the child outside the education and care service premises

AUTHORISED NOMINEE 3:

Nominee 3 First Name

Nominee 3 Last Name

Address

Street Address City State / Province / Region Postal / Zip Code

Phone

### - ### - ####

Relationship to Child

Please indicate below which authorisations apply to this nominee. Please select as many as apply:

1. This person is to be notified of an emergency involving the child if a parent of the child cannot be immediately contacted and is authorised to Collect the child from the service if needed(at least one nominee must be authorised in this category)

2. Authorised to Collect the child from the service

3. Authorised to consent to medical treatment of, or to authorise administration of medication to, the child

4. Authorised to authorise an educator to take the child outside the education and care service premises

AUTHORISED NOMINEE 4:

Nominee 4 First Name

Nominee 4 Last Name

Address

Street Address City State / Province / Region Postal / Zip Code

Phone

### - ### - ####

Relationship to Child

Please indicate below which authorisations apply to this nominee. Please select as many as apply:

1. This person is to be notified of an emergency involving the child if a parent of the child cannot be immediately contacted and is authorised to Collect the child from the service if needed(at least one nominee must be authorised in this category)

2. Authorised to Collect the child from the service

3. Authorised to consent to medical treatment of, or to authorise administration of medication to, the child

4. Authorised to authorise an educator to take the child outside the education and care service premises

CHILD'S HEALTH INFORMATION

Doctor/ Medical Service Details:

Doctor's Name *

First Last

Medical Centre Name and Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code

Medical Centre Phone Number *

### - ### - ####

Child's Medicare Card Details:

Card Number: *

Child's Individual Reference Number: *

Does the child have a developmental delay or disability including intellectual, sensory or physical impairment? *

Yes

No

If Yes, please provide the details of any developmental delay or disability and any management procedure to be followed with respect to the delay or disability.

DOES YOUR CHILD HAVE ANY SPECIAL NEEDS? *

If Yes, please provide the details of any special needs and any management procedure to be followed with respect to the special need.

DOES YOUR CHILD HAVE ANY ALLERGIES OR SENSITIVITIES?

Please note that if your child has been diagnosed at risk of ALLERGY, a medical managment Plan, together with all specified medication, must be provided to the centre prior to the child's Commencement. *

If Yes, please provide further details in relation to the ALLERGY or allergies below including allergens or triggers:.

HAS YOUR CHILD BEEN DIAGNOSED AT RISK OF ANAPHYLAXIS?

Please note that if your child has been diagnosed at risk of ANAPHYLAXIS, a Medical Management Plan, together with all specified medications, must be provided to the centre prior to the child's commencement. *

Does Your Child Have an Auto Injection Device (e.g. Epipen?) *

If Yes, please provide further details in relation to ANAPHYLAXIS below including allergens or triggers:.

OTHER MEDICAL CONDITIONS

Does your child have any other medical conditions (e.g. Asthma, Epilepsy, Diabetes, Eczema etc.) that are relevant to the care of your child? *

If Yes, please note that if your child has been diagnosed at risk of any medical condition, a medical management plan, together with all specified medication, must be provided to the centre prior to the child's commencement.

Please provide further details of any medical condition below:

Does your child have any Cultural, Religious or Dietary Restrictions? *

If Yes, please indicate which restrictions apply below:

Is Your Child Fully Immunised? *

Please Upload a Current Copy of your Child's Immunisation History Statement from the Australian Immunisation Register here. Please note this must be the verified PDF version of the certificate obtained from Medicare and not a screenshot. *

Has your child ever had any of the following? Please select all options that apply to your child *

Did Your Child Develop Normally in the Following Areas?

Talking *

Feeding *

Sleeping *

Walking *

Does Your Child Ever Have or Suffer From Any of the Following? Please Select All Options that Apply to Your Child *

Are you Concerned about any of the Following? *

Hearing

Speech

Sight/Vision

NONE OF THE ABOVE

Is Your Child Toilet Trained? *

If your child is still in nappies, do you give permission for nappy cream to be applied by staff in the event of nappy rash if none has been supplied by you? *

Please comment on any of the health and development items above or please add any addtional information that is relevant to your child here:

CHILD CARE SUBSIDY INFORMATION:

Assistance with the cost of Child Care

Will you be claiming Child Care Subsidy *

Please note that the person listed in Parent 1 above must also be the claimant for child care subsidy.

Customer Reference Number for Parent 1 above:
(your customer reference number must consist of 9 numerals and 1 letter)

Customer Reference Number for Child:

Does your Child Use another Child Care Service? *

COMPLYING WRITTEN ARRANGEMENT:

This form is required for each child enrolled at our centre.

This Written Arrangement between

Parent Name *

First Last

and North Balwyn Playcentre Incorporated is an ongoing agreement to provide care in return for fees. The Written Arrangement must contain a minimum amount of information set out in subsection 200B(3) of the Family Assistance Administration Act.

DEFINITIONS:

1. Complying Written Arrangement CWA:
Select this option if you wish to claim CCS now or in the future. If you do not select an arrangement type this arrangement type will be chosen for you as a default.

2. Relevant Arrangement RA:
Select this option if you do NOT wish to or are NOT eligible to claim CCS now or in the future.

3. Additional Child Care Subsidy
ACCS ACCS replaces the Special Childcare Benefit, Grandparent CCB and Jet CCFA
Circle this option if you are entitled to ACCS under the new Child Care Subsidy

4. Arrangement with an organisation
Arrangement where an outside organisation is liable for the fees of the care of the child

Please select the Arrangement Type Applicable to your Enrolment. *

Name of Service: North Balwyn Playcentre Incorporated

Service Approval Number: SE:00016209

Parent/Guardian Full Name *

Parent Guardian Phone Number *

### - ### - ####

Date The Arrangement Was Entered Into (today's date) *

DD / MM / YYYY

Child's Name *

First Last

Child's Date of Birth *

DD / MM / YYYY

Expected Days of Care *

CARE ARRANGEMENT:The type of care the service offers and the parent accepts is considered “flexible care.” Although our service offers permanent days of care we also like to offer the opportunity for casual days where available.
FEES TO BE CHARGED TO THE INDIVIDUAL FOR THE SESSIONS OF CARE PROVIDED:
A full list of current fees and charges are available in our Fees Policy. These are subject to change with written warning. Please refer to our : FEES POLICY for further details.

Date *

DD / MM / YYYY

OTHER INFORMATION ABOUT YOUR CHILD?

Is there anything else that the children's service should know about your child? (e.g. excessive fears, favourite activities, developmental delay or disability, attending other early childhood service or early interventions service etc. PLEASE PROVIDE DETAILS BELOW: *

Does Your Child Have Any Siblings? *

If yes please provide the names and ages of siblings below:

Does Your Child Have Any Pets? *

If yes please provide the pet type and the names of pets below

Please tell us about the things that interest your child *

What do you hope your child will learn whilst at our centre? *

AUTHORISATIONS

Declaration and Consent to Emergency Medical Treatment

I, (Parent First Name) *

(Parent Last Name) *

a person with lawful authority of the child referred to in this enrolment form,

* Declare that the information in this enrolment form is true and correct and undertake to immediately inform the children's service in the event of any change to this information;

* agree to collect or make arrangements for the collection of the child referred to in this enrolment form if s/he becomes unwell at the service;

*consent to the proprietor to seek medical treatment for the child from a medical practioner, hospital or ambulance service

*consent to transportation of the child by an ambulance service at my expense.

Signature *

Clear

Date Consent Granted/ Declaration made: *

DD / MM / YYYY