child enrolment form (1)

7/31/2019 Child Enrolment Form (1)

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Family Day Care Services _____________________________________________________________________________________

1 We Care The Way You Care

Enrolment Details Date:

A parent or guardian who has lawful authority in relation to the child must complete this form. Brief explanation of lawful authority is found at

the end this form. Li censed childrens services may use this form to collect the childs enrolment information as required in regulations 31to35 . Questions marked with an asterisk * are not required by the regulations, but you are encouraged to answer these to assist the service in

caring for your child.

Information about the child

Parent/Guardian Information

Mother Father

Name: Name:

Address-as per child or: Address-as per child or:

Telephone/s

(H)

Telephone/s

(H)

Family Name:Date of Birth: ....Sex: M F

Given Name/s ....

Home Address: .

Cultural Background.

Language(s) spoken in the home: Place of Birth: ..

* Is the child of Aboriginal and? Or Torres islander origin?

O No, Not aboriginal and/or Torres Strait Islander O Yes, Aboriginal and / or Torres Islander

* Is the child has a developmental delay or disability including intellectual, sensory or physical impairment?

O No, or Yes (please circle)


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(Mobile)

Email:

(Mobile)

Email:Country of Birth: Country of Birth:

Does the child live with the mother?

No Yes (please tick)

Does the child live with the father?

No Yes (please tick)

Occupation: Occupation:

Guardian Guardian

Name: Name:

Address-as per child or: Address-as per child or:

Telephone/s

(H)

(Mobile

Telephone/s

(H)

(Mobile

Does the child live with this guardian? Does the child live with this guardian?

Priority 1 a child at risk of serious abuse or neglect

Priority 2

a child of a single parent who satisfies, or parents who both satisfy, thework / training / study test under section 14 of the Family Assistance Act Priority 3 any other child

Which Priority group is the parent/guardian in? (Please tick) Priority 1 Priority 2 Priority 3

Other persons to be notified

There may be times when the child has an accident, injury, trauma or illness and the parents or guardians cannot be contacted. To deal with

these situations the childrens service should notify one of following people who are authorized to collect and care for the child after accident,

injury, trauma or illness

Name: Name:Address: Address:

Telephone/s

(H)

Telephone/s

(H)


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(Mobile) (Mobile)

Relationship to child: Relationship to child:

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?

No go to the next section yes please complete the following:

1. Bring the original court order/s for staff to see and a copy to attach to this enrolment form:

2. If these orders:

a) change the powers of a parent/guardian to:

Authorize the taking of the child outside the service by a staff member of the service;

Taking the child outside the Kids CommunityHome Based Educator s residence or venue by

another Home Based Educator,

consent to the medical treatment of the child;

Request or permit the administration of medicine to the child;

Collect the child from the Home Based Educator residence, AND/OR

b) give these powers to someone else,

Please describe these changes and provide the contact details of any person given these powers:

..

Details of people who you authorise to collect your child

There Your consent is required for other people to collect the child from the chi ldren s service on your behalf. In the table below please list the

details of those people you have authorized to collect the child. This list may be added to or changed through the year. In t he event that the

child is not collected from the childrens service and parents or gua rdians cannot be contacted, this list will also be used to arrange someone

to collect the child.


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Name: Name:

Address: Address:

Telephone/s

(H)

(Mobile)

Telephone/s

(H)

(Mobile)


Name: Name:

Address: Address:

Telephone/s

(H)

(Mobile)

Telephone/s

(H)

(Mobile)


Childs Health information

Name of Doctor/Medical Service :Telephone:

Address of Doctor/Medical Service:

Does your child have a health record?

If yes, please provide to Kids Communityfor sighting.

Child health record means a record that d ocuments a childs health and development assessments and immunizations.

Name and Position of person at Kids Community who has sighted the childs health record.

Name:Position:


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Childs Medical Information

Does your child have any special need? No Yes (please stick )

If Yes, please provide details of any special needs and any management procedures to be followed with respect

to the special need.

Does your child have any allergies or sensitivity? No Yes

If Yes, please provide details of any sensitivities and management procedure to be followed with respect to the

sensitivity. Pleas attach an Action Plan for Anaphylaxis if the child has any allergies.

Anaphylaxis

Has your child been diagnosed at risk of anaphylaxis? No Yes

Does your child have an auto injection device (eg Epipen)? No Yes

Has the Anaphylaxis Act ion Plan been provided to Kids Community? No Yes

Has a risk managem ent plan been completed by Kids Community consultation with you? No Yes

In the case of anaphylaxis you will be provided with a copy of the Kids Communityanaphylaxis management

policy. You will be required to provide Kids Communitywith an Anaphylaxis Action Plan for your child signed by

the medical practitioner who is treating your child. This will be attached to your childs enrolment form. More

information is available at www.education.vic.gov.au/anaphylaxis

Does your child have any other medical conditions? (eg asthma, epilepsy, diabetes etc that is relevant to the care

of your child)

If yes, please provide details of any medical condition and any management procedures to be followed with

respect to the medical condition.

Childs Medication Authorization

I, authorize my Kid s Community Home Based Educator, as p

medical plan or in the event of an emergency, administer medication to my child(ren).

Parent/Guardian:

Sign:..


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.

Does the child have any dietary restrictions?If yes, the following restrictions apply:

......

Childs Immunisation Records

Has the child been immunized?

If yes , provide the details by:

Attaching a copy of the Immunization Record from the child health record book OR

Attaching a copy of the Immunization Record printout from local government OR

Attaching a Child History Statement from the Australian Childhood Immunization Register OR

Completing the table below using the childs immunization Record to provide the date of immunizations

received

Immunization (valid from March 2008) Birth 2months 4months 6months 12months 18months 4months

Hepatitis B

Diphtheria, tetanus & a cellular pertussis

(DTPa)

Haemophilus influenza (Type b)

Inactivated poliomyelitis (IPV)

Pneumococcal conjugate (7vPCV)

Rotavirus

Measles, mumps & rubella (MMR)


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Meningococcal C

Varicella (VZC)

Additional immunisations for Aboriginal and Torres Strait Islander children (if required)

Hepatitis A 12 - 24months

18 - 24

months

Pneumococcal polysaccharide (23vPPV)

*Other Information

If there is anything else that Kids Communityshould know about the child? (e.g. excessive fear, favorite

activities, attending other early childhood service or early intervention service, etc)

Declaration and consent to emergency medical treatment

I,(Print full 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 Kids Community 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 during the Care Period;

Consent to Kids Communityto seek medical treatment for the child from a medical practitioner, hospital

or ambulance service.

Parent Name .ParentSignature

Date/ /20


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Confidentiality of enrolment records

The proprietor of the childrens service must ensure that the information in this enrolment record is not divulged toanother person unless necessary for the care or education of the child, to manage medical treatment of the child,

where expressly authorized by the parent or prescribed in the Childrens Service Regulations 2009 (regulation

35(1) (de))

Lawful Authority

Parents

All parents have powers and responsibilities in relation to their children that can only be changed by a court order.

The Childrens Service Regulations 2009 refer to these powers and responsibilities as lawful authority. It is notaffected by the relationship between the parents, such as whether or not they have lived together or are married.

A court order, such as under the Family Law Act , may take away the authority of a parent to do something, or

may give it to another person.

Guardians

A guardian of a child has lawful authority. A legal guardian is given lawful authority by a court order. The definition

of guardian under theChildrens Services Act 1996 also covers situations where a child does not live with his or

her parents and there are no court orders. In these cases, the guardian is the person the child lives with who has

day-to-day care and control of the child.


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Agreement & Consent to Terms

Childs Name: _________________________________________________Date of Birth: _________

1. Emergency or Accidents

In the event of an emergency, illness or accident, I / We give the educators at the Kids Community consent toprovide Medical or Hospital attention for our child. I / We agree to pay any expenses incurred for Medical treatmentand Transport.

2. Administering of Paracetamol

I / We agree for Educators to administer ONE dosage of Paracetamol in the event of our childs body temperature

rising above 38C. I / We understand that the staff will make contact with either the Parents / Guardians or theEmergencyContacts to inform us that Paracetamol is being administered and discuss at the time further actions to take in theevent that the temperature does not subside within an appropriate time frame.

3. Permission for Publication

I / We hereby give consent for our childs photograph, name and age to be used for the room programming,Coordination Unit displays and/or publications (e.g. Newsletters) or Kids Community website. Where this informationmay be utilized outside of the coordination unit, further permission will be sought.

4. Permission for Observation

I / We give permission for our child to be observed for educators, student or researchers purposes. Students andresearchers will be from accredited training programs and will work in conjunction with your childs educators. If questioning or testing is to be carried out I / we will be asked for further permission.

5. Payment of Fees

I / We agree to maintain our fees as per the coordinations fee policy. We will ensure our fees are kept up to date bymaking payments on the required day via direct Debit or as agreed with the coordination unit.I / We give permission for Kid's Community FDC to send invoices through email.I / We are aware that failure to pay due fees within 14 days may result in the cancellation of care at the home basededucators option. Where a direct debit arrangement has been entered into, I/we authorize the coordination unit tomake withdrawals from my/our nominated account as specified in the Direct Debit Request Form, as determined thecoordination unit in accordance with the terms and conditions herein and in any subsequent agreement with the

coordination unit. I/we acknowledge that such withdrawals may include amounts representing any arrears that areowed by us. I / We understand that any costs incurred by the centre in collecting any arrears owed may be charged tomy/our account.

6. Sunscreen Application

I / We agree for t he educators of Kids Community to apply sunscreen regularly to our child for outdoor play purposes.I / We understand that the educators may use a variety of sunscreen brands from time to time. If my child requiresspecial sunscreen I/we agree to supply this product to the educator.


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7. Insect Repellant Applications

I / We agree for educator to apply Insect Repellant to our child where necessary for indoor or outdoor purposes.

I / We understand that the educator may use a variety of insect repellant brands from time to time. If my child requiresspecial repellant. I/we agree to supply this product to the educator.

8. Child Care Benefit (Lump Sum Claims)I / We understand that it is our responsibility to notify the Centre of our Customer Reference Numbers (CRNs) evenwhere our family will not be claiming Child Care Benefit as reduced fees on a fortnight basis.

9. Parent Handbook

I / We acknowledge that we have read the Kids Communitys Parent Handbook. I / We understand any changes tothis Handbook will be displayed on the Parent Communication Boards in the Coordination Unit office or on our website.

10. Centre Policies

I / We acknowledge that the coordination unit Policies are available in the Kids Communitys office at all times toview. I / We understand that any changes to these policies will be carried out where appropriate in consultation withus as Parents / Guardians and any changes to these policies will be displayed on the Parent Communication Boardsin the Kids Community Office.

11. Cancellation of Care

I / We understand that two weeks written notification is required in advance when cancelling care.

12. Fees for Public Holidays

I / We understand that Public Holidays are charged at the higher daily fee rate

13. Priority of Access

I / We understand that if our family falls under Priority Access we may be required to alter our days in order to providea place for a higher Priority family according to the following Priority Access Guidelines and our Policy:

First Priority children at risk or serious abuse or neglect; Second Priority children whose parents satisfy the work,training and study guidelines specified by the Government; and Third Priority all other children.

14. Infectious Diseases / Clearance Certificates

I / We u nderstand that our child will be excluded from the educators home if they contract a contagious disease or

condition. I / We understand that our child will not be accepted back into the educators home until a clearancecertificate is issued from a Medi cal Practitioner. Please refer to our Policies for further information.

15. Non Immunisation

I / We understand that if our child is NOT immunised in accordance to the Government requirements (refer to our immunisation details page) our child will be excluded from the centre until the infectious period of the disease or condition has passed. (Please refer to our Policies for further information)


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16. Confidentiality of Enrolment Records

I/We understand that information in the childs enrolment record is not divulged to another person unless necessaryfor the care or education of the child, to manage medical treatment of the child, where expressly authorised by theparent or prescribed in the Children Services.

17. Authorisation for childs transportation and participation in excursions

I GIVE PERMISSION FOR MY Home Based Educator of KID S CUMMUNITY FDC TO

TRANSPORT/EXCURSION MY CHILD(REN).

TRANPORT METHODS (please CIRCLE one or more)

Bus Tram Train Car Walk or All

18. Lawful Authority

All parents have powers and responsibilities in relation to their children that can only be changed by a court order.The Childrens Services Regulations 2009 refer to these powers and responsibilities as lawful authority. It is notaffected by the relationship between the parents, such as whether or not they have lived together or are married. Acourt order, such as under the Family Law Act, may take away the authority of a parent to do something, or may giveit to another person.

Guardians

A guardian of a child also has lawful authority. A legal guardian is given lawful authority by a court order.The definition of guardian under the Childrens Services Act 1996 also covers situations where a child does not livewith his or her parents and there are no court orders. In these cases, the guardian is the person the child lives withwho has day-to-day care and control of the child.

By signing this form I/we declare and confirm:

I / We are lawfully authorized in relation to the Child referred to in this Enrolment Form; All information provided in this Enrolment Form is true and correct; and I/we have read, fully understand and agree to comply with all of the policies and procedures detailed in thisEnrolmentForm including items 1 to 17 above, and any other policies and procedures advised by the centre eitherdirectly or by making them available for perusal at the Centre.

Signature of Primary Parent/Guardian: ___________________________________Date: ________ Signature of Secondary Parent/Guardian): ________________________________Date: ________

By law, appropriate child restrains must be used in accordance with childs weight and height.

Also Home Based Educators will ensure the following items before departure: contact phone numbers, First Aid Kit and Asthma, Anaphylaxis medication for excursion


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Agreed Hours Form

Child First Name: ___________________________________________Surname: ___________________________________________

Please circle the type of care you require:

Permanent Casual B/A School School Holiday

Days requiring care:

Monday From:To:

Tuesday From:To:

Wednesday From:To:

Thursday From:To:

Friday From:To:

Saturday From:To:

Sunday From:To:

I agree to pay fees for the days that I have chosen above. I understand whether I use or not will be charged for mychosen days. I also understand that I have to give two weeks notice if intend to leave the care.

Parent Email:

Parent First Name: ___________________________________________ Surname: __________________________________________

Familys Signature: ____________________________________________________

Educator First Name: ___________________________________________ Surname: __________________________________________

Educators Signature: __________________________________________________

Commencing Date: __________________________________________________


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CCB INFORMATION

To ensure that you are linked to our centre through the Child Care Management System (CCMS) and to have ChildCare Benefit (CCB) applied to your child care fees, you must contact Centrelink to confirm that they have the correctname and date of birth for both the parent & child who are registered for CCB.

Please complete the following information accurately to ensure that your CRN is linked to our centre and to enableyou to receive CCB:

Person Registered for CCB with Centrelink (details must be EXACTLY as per Centrelinks Records)

Full Name: __________________________________________________________________________________

Date of Birth: _____________________________________ CRN: _____________________________

Child Registered for CCB with Centrelink (details must be EXACTLY as per Centrelinks Records)

Full Name: ____________________________________________________________________

Date of Birth: _____________________________________ CRN: _____________________________

Has this child attended another child care service this financial year? _ Yes _ No

Is the child attending multiple child care services? _ Yes _ No

Verification of Details held by Centrelink

I confirm that:1. The information I have provided above is true and correct and that I have provided Centrelink with this sameinformation.2. I am responsible for communicating this information to Centrelink.3. I understand that I am responsible for all fees charged by the centre in relation to this enrolment.4. I understand that if any details are incorrect then full child care fees are payable by me directly to the centre untilthe details are corrected with Centrelink.

Name: _______________________________ Signature: _________________________________

Date: _____________________

child enrolment form (1)

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