2016 Child Enrolment Form

Transcription

1 Child Outside School Hours Care 2016 Child Enrolment Form Service St Rose Outside School Hours Care 8 Rose Avenue, Collaroy Plateau NSW 2097 Phone: collaroy.oshc@dbb.org.au Website: Office Use Only: Attendance Requested - please tick Before School Mon Tues Wed Thurs Fri After School Start Date: Immunisation Records supplied? Yes No (Note: Regulation 162 requires the service to keep information about the child s immunisation status) Health Action Plans supplied, if applicable? Yes Comments: No N/A 1

2 CHILD ENROLMENT FORM CHILD DETAILS First name: Preferred first name: Surname: Sex: Male Female Date of Birth (DD/MM/YY): Name of school attending: CRN: Aboriginal/Torres Strait Islander: Yes No Place of Birth: Religion: Language spoken at home: Cultural Background: Address (including suburb and postcode): PARENT/GUARDIAN DETAILS 1 PARENT/GUARDIAN DETAILS 2 Date of Birth: Occupation: Employer: Work days/hours: Ethnic/cultural background: Aboriginal/Torres Straight Islander: Yes No CRN: Date of Birth: Occupation: Employer: Work days/hours: Ethnic/cultural background: Aboriginal/Torres Straight Islander: Yes No CRN: Nominate which CRN you wish to use for the enrolment: Has the nominated person been assessed for Child Care Benefit? Yes Who is liable for the payment of child care fees? No AUTHORISATIONS FOR, COLLECTION OF CHILDREN FROM SERVICE, EMERGENCY CONTACTS, MEDICATIONS, EXCURSIONS 2

3 I hereby authorise those people listed below to undertake the following responsibilities by signing here and placing a tick of agreement in the relevant boxes. Parent/Guardian Signature: Date: Person 1 Person 2 I agree for this person to: I agree for this person to: Have access to my child and for staff to allow the person to collect my child from the service. I will give prior notice to staff on the days that the person will be collecting my child from the service. service. Be contacted in the case of an emergency and authorise medical treatment if parent/guardian cannot be immediately contacted. Give consent for the administration of medication Give consent for staff to take my child outside of the centre premises for the purpose of an excursion. Have access to my child and for staff to allow the person to collect my child from the service. I will give prior notice to staff on the days that the person will be collecting my child from the Be contacted in the case of an emergency and authorise medical treatment if parent/guardian cannot be immediately contacted. Give consent for the administration of medication Give consent for staff to take my child outside of the centre premises for the purpose of an excursion. Relationship to child: Relationship to child: Person 3 Person 4 I agree for this person to: I agree for this person to: Have access to my child and for staff to allow the person to collect my child from the service. I will give prior notice to staff on the days that the person will be collecting my child from the service. service. Be contacted in the case of an emergency and authorise medical treatment if parent/guardian cannot be immediately contacted. Give consent for the administration of medication Give consent for staff to take my child outside of the centre premises for the purpose of an excursion. Have access to my child and for staff to allow the person to collect my child from the service. I will give prior notice to staff on the days that the person will be collecting my child from the Be contacted in the case of an emergency and authorise medical treatment if parent/guardian cannot be immediately contacted. Give consent for the administration of medication Give consent for staff to take my child outside of the centre premises for the purpose of an excursion. Relationship to child: Relationship to child: COURT ORDERS Are there any Court Orders pertaining to, or custody of, or residence of your child? 3

4 (Please provide copies of any Court Orders) Yes No Are there any Parenting Orders or Parenting Plans in place for your child? (Please provide copies of any Parenting Orders/Plans) Yes No MEDICAL INFORMATION Doctor Dentist Phone: Medicare Number: Health Fund Provider and Number: Phone: HEALTH BACKGROUND Has you child been immunised? Yes No Is it up to date? Yes No Note: An Australian Childhood Immunisation Register (ACIR) Immunisation History Statement must be supplied Has your child had any of the following? Measles German Measles Hepatitis Mumps Ear Infection Chicken Pox Throat Infection Other Does your child have any medical condition that is being treated or monitored? (eg asthma, diabetes, epilepsy. Please list, including brief treatment summary a Medical Action Plan and Risk Minimisation Plan may be required) Does your child have any allergies or is at risk of anaphylaxis? (Please list, including brief treatment summary a Medical Action Plan and Risk Minimisation Plan may be required) Does your child have any dietary restrictions? Yes No If yes, please provide details of the restrictions: Does your child have a disability? (If your child has a disability how does the disability affect your child? Please give details including mobility, toileting and communication) 4

5 Do you, or have you had, concerns about your child s speech development, eye sight or hearing? Are there any other concerns or anything else you may wish to tell us about your child? (ie behaviour, disposition, family history) Have any records related to the child s health been supplied or shown to service staff? Yes No If yes, please give details of the type of record: CHILD PROFILE Do you wish your child to complete any homework whilst at the centre? Yes No Homework If yes, please give details of how you would like this approached. Personality Does your child have any particular fears staff should be aware of? Please describe any special interests or favourite activities your child has? FAMILY PROFILE Siblings DOB: DOB: DOB: DOB: 5

6 Relationship to Child: Other Significant Household Members Relationship to Child: Skills: Family/parent interests which you may be able to share with the Centre Special Training: Creative Activities: Other: Special days/events celebrated(please list) What sort of experiences are you hoping for your child to have while at outside school hours care? ADDITIONAL INFORMATION Would you like to list any special considerations such as cultural, religious or dietary preferences, or additional needs for our staff to be aware of? AUTHORISATIONS Parent/Guardian Child s Date: Signature (Please sign below) I authorise the staff at the Centre CatholicCare Diocese of Broken Bay, to Seek urgent medical treatment from a registered medical practitioner, dental service, hospital or ambulance service Have the urgent medical treatment be carried out. Have the child transported by ambulance if deemed necessary I understand any cost will be borne by the parent/guardian. I give permission for staff to take photographs of my child for use in the following (please tick agreed points): My Child s Observations/Portfolio Other Children s Observations/Portfolios (ie group shots) Display within the Centre Display in the Centre Newsletter 6

7 Use in program documentation sent to families via Slideshow presentations with Catholic Schools Office Staff Slide Show Presentations for Children s Services Staff and/or CatholicCare Staff - Professional Development training I understand that specific permission will be sought for photographs to be published in newspapers, professional journals and on websites. I understand that I am only allowed to photograph my own child while on the centre premises. I also understand that group photographs/media taken of groups of children, by service staff, at special events (eg Christmas parties etc) and photos included in the children s documentation are not to be distributed to other people or placed upon social media and/or other web sites for anyone else to view. I authorise the staff to apply sun screen as required and as per the Sun Protection Policy. I do / do not (please circle) give permission for staff to administer Paracetamol once according to the manufacturer s instruction and the Medication Policy in the case of a fever greater than 38.5 I recognise all attempts will be made to control the fever, including removing excess clothing and encouraging fluid intake, and making contact with parents/guardians to inform them of the situation. I do / do not (please circle) give permission for staff to administer an EpiPen once and in accordance with the Managing Asthma Allergies Anaphylaxis Diabetes and Other Medical Conditions Policy and the Medications Policy in the event that my child has an anaphylaxis emergency while at the centre. I understand that all attempts will be made to contact parents immediately and that an ambulance will be called. I do / do not (please circle) give permission for staff to administer asthma reliever medication in accordance with the Managing Asthma Allergies Anaphylaxis Diabetes and Other Medical Conditions Policy and the Medications Policy in the even that my child has an asthma emergency while at the centre. I understand that all attempts will be made to contact parents immediately and that an ambulance will be called. I certify that the information contained in this enrolment form is correct. I will immediately inform the Coordinator of any changes to this information. I have read, understood and agree to abide by the centre s information, policies and procedures. 7

8 Office Use Only Application Complete and Entered into the Centre s System (Date) 8