Enrolment Form 80-82 Wilmoth Street Thornbury 3071

Enrolment Form
80-82 Wilmoth Street
Thornbury 3071
Ph: 9480-2111
Info@thornburykids.com.au
www.thornburykids.com.au
ENROLMENT FORM & CONDITIONS
HOURS:
TERMINATION OF SERVICES:
The normal hours of operation are: 7.00am to 6.00pm
Two weeks notice is required for withdrawal from the centre.
Monday to Friday
Your two weeks in advance will cover you for the notice period.
APPLICATION FEE:
PUBLIC HOLIDAYS:
Upon enrolment an application fee of $100.00 is required to secure your
Public Holidays must be paid for in full if you are booked in
child’s place. This application fee is a non refundable fee.
on that particular day
FEES:
Fees are due and payable prior to the care of your children.
Fees are due on Mondays 2 weeks in advance, and must remain
in advance for the duration of care being provided to your child.
HOLIDAYS:
Holidays are billed at full rates
You must give 2 weeks notice prior to holidays commencing.
SICK DAYS:
LATE FEE:
Families are required to pay for any days their child is absent
A late fee of $1.00 per minute will be charged for each 5 minutes or
from the centre.
part thereof that your children remain at the centre after
6.00pm. We are required to retain two staff members at all
ENROLMENT FORMS:
times the children are at the centre and staff must be paid at
It is a requirement that a departmental approved enrolment
overtime rates.
form is fully completed and signed by the parent/guardian.
Failure to comply in this regard will prevent your child being
SICKNESS:
allowed admission to the services of the centre. Please ensure
If a child appears to need medical attention whilst in the care
you complete all required fields.
of the centre, the management reserves the right to seek
immediate medical aid, on behalf of, and at the cost of,
parents and/or guardians. The latter will be notified of any
I/We acknowledge and confirm our understanding
medication administered or any medical treatment provided to
of the above:
the child while at the centre or in our care. These facts will also
be documented appropriately.
Signed:
MEDICAL:
A medical certificate stating that the child is over any infectious
Print name:
period will be required before the child will be allowed to
resume attendance at the centre.
Date:
PERSONAL POSSESSIONS AND CLOTHING:
No responsibility will be taken for any personal possessions
and clothing. All of these items must be clearly and indelibly marked with
Signed:
the child’s name.
Print name:
Date:
Thornbury Kids Confidential Enrolment Form
2
CONFIDENTIAL PARENT/CENTRE ENROLMENT FORM
Orientation date:__________________ Admission date:____________________
(A) Child’s details
Name:
Male/Female:
Address:
Date of birth:
Country of birth:
Telephone:
(B) Parent/guardian with whom the child resides
Mother/Guardian:
Telephone:_________________
Address:
Mobile:
Relationship:
Tel (wk):
Date of Birth
Father/Guardian:
Telephone:
Address:
Mobile:
Relationship:
Tel (wk):
Date of Birth
Email address for account statements & newsletters:
(C) Emergency contact person other than parent
There may be the need, in time of accident, trauma or illness, that parent or guardians cannot be contacted. To deal
with these situations the children’s service should notify the following person who is authorised to collect and care for
the child.
Name:
Telephone:
Address:
Mobile:
Occupation:
Tel (wk):
Languages spoken at home:
Is the child of Aboriginal and/or Torres Straits Islander descent? ___YES ___NO
Has the child attended any other Day Care Centre, Pre-School or Play Group? ___YES ___NO
If yes, please give details:
Thornbury Kids Confidential Enrolment Form
3
COURT ORDERS
Are there any court orders relating to the powers and responsibility of the parents in relation to the child or
access to the child?
NO go to the next question
YES please complete the following
1. Bring the original court orders 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
Authorise the taking of the child outside the service by a staff member of the service;
Consent to the medical treatment of the child;
Request or permit the administration of medication to the child;
Collect the child and/or
b) Give the powers to someone else;
please describe these changes and provide the contact details of any person given these powers.
Name:
Telephone:
Address:
Mobile:
Relationship:
Tel (wk):
PERSONS AUTHORISED TO COLLECT CHILD FROM PREMISES
Your consent is required for the other person to collect the child from the children’s service on your behalf if for some
reason you are not able to collect your child from the service..
Please list the details of the person(s) who can collect the child/children in the space provided below.
Name:
Telephone:
Address:
Mobile:
Relationship:
Tel (wk):
Name:
Telephone:
Address:
Mobile:
Relationship:
Tel (wk):
Signed Parent/Guardian:
Date:
Witnessed by Director:
Date:
MEDICAL INFORMATION
Medicare number:
Ambulance number:
Healthcare number:
Pension number:
Doctor:
Telephone:
Medical Centre Address:
Thornbury Kids Confidential Enrolment Form
4
GENERAL HEALTH
Please list any items of significance in relation to your child’s health:
Does the child have any allergy or sensitivity? __YES __NO
If yes, the following management procedures are to be followed. (A copy of the management plan must be attached.)
Allergy:
Treatment:
Allergy:
Treatment:
Allergy:
Treatment:
Your child cannot attend the centre without an Epi Pen authorised by a Medical Practioner
Dietary restrictions? ___YES ___NO
If yes, please explain
Does the child have any medical conditions and needs (e.g. Epilepsy, Diabetes, Asthma etc.) which are relevant to
the children’s service? ___YES ___NO
If yes, the attached management procedures are to be followed. (Ensure you provide a copy.)
IMMUNISATION STATUS
Has your child been immunised and is upto date? ___YES ___NO
If yes, you must provide the details by:
Attaching a copy of the immunisation record from the child health record book
OR
Attaching a copy of the immunisation record print-out from the local government
Cultural and Religious Background Information:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Does the child have a developmental delay or disability including intellectual, Sensory or physical impairment?
___YES ___NO
Does either parent have a disability? ___YES ___NO
Thornbury Kids Confidential Enrolment Form
5
Is the family a single parent family? ___YES ___NO
CONFIDENTIAL FURTHER INFORMATION
Is there anything else that the children’s services should know about the child e.g. excessive fears, favourite activities
etc.
FURTHER INFORMATION
Family reference number:
Child reference number:
Email address for billing of childcare statements:
Parents/Guardians Occupation: __________________________________________________________________
Attendance
Monday
Tuesday
Wednesday
Thursday
Friday
□
□
□
□
□
Thornbury Kids Confidential Enrolment Form
6
HOW DID YOU FIND OUT ABOUT Thornbury Kids
Please tick the boxes indicating what sparked your interest in Thornbury Kids . Please provide details where
appropriate.
This enables us to assess the value of our advertising and to thank our supporters.
Sign at site
Word of Mouth
Letterbox Drops
Websites
www.thornburykids.com.au
www.careforkids.com.au/
www.echildcare.com.au
www.findvacancies.com.au
Yellow Pages
White Pages
Local Paper Advertisements
Maternal and Child Health Centres
Schools
Kindergartens
Local Doctor/Medical Centre
Real Estate Agents
Churches
Family Friendly Places
Video Stores
Libraries
Toy Libraries
Play Centres
Play Groups
Marvellous Mums
Another family
Staff member
Other (please specify).
Thornbury Kids Confidential Enrolment Form
7
PHOTOGRAPHS Often in our centre we use photo displays of the children.
PHOTOGRAPH PERMISSION
I do/ do not give permission for my child’s photo to be taken to be used for the purpose of displays.
Parent/Guardian Signature
IIIIIIIIIIIIIIIIIIIIIIIIIIIII
DECLARATION AND CONSENT TO EMERGENCY MEDICAL TREATMENT
I (print name in full)
referred to in this enrolment form:
,a person with lawful authority of the child
• 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
enrolment;
• Agree to collect or make arrangements for the collection
of the child referred to in this enrolment form if he/she
becomes unwell at the service;
• Consent to the staff of the children’s service seeking,
or where appropriate, administering such emergency
medical treatment as is reasonably necessary and
that I will reimburse any necessary expenses incurred
by the children’s service.
Full name and Signed by Parent/Guardian:
Date:
Signed Director:
Date:
Parent Feedback:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Thornbury Kids Confidential Enrolment Form
8