KIDSPACE

Enrolment Form
Childs Details:
Name 1__________________________ DOB_____
2__________________________ DOB_____
3__________________________ DOB_____

male/female
male/female
male/female

Home Address ___________________________________________

E-mail Address___________________________________________
Ethnicity (for statistics only)________________________

Enrolment Details:
Circle as appropriate:
Full time enrolment
Part time enrolment
Casual Enrolment

Mon to Fri
Mon Tue Wed Thurs Fri
days to be notified

Time of attendance (3pm to 5.30)

Please write times Mon_________
Tue_________
Wed_________
Thurs________
Fri__________

Start date___________________

People authorised to pick up your child(ren):

Name____________________________
Name____________________________
Name____________________________

Parent/Caregiver Details:
Parent/Caregiver #1 Name:___________________________________
Telephone (between 3-5:30) ____________(cell phone)______________
Home phone_____________
Parent/Caregiver #2 Name:___________________________________
Telephone (between 3-5:30) ____________(cell phone)______________
Home phone_____________
Emergency Contacts:
Name:_____________________
Phone:_______________________
Relationship to child:_________________________________________
Name:_____________________ Phone:________________________
Relationship to child:________________________________________
Health Information:
Family Doctors
Name:____________________________________________________
Address:__________________________________________________
Phone:_____________________
Does your child have any particular health needs which we should be aware
off? (allergies, medication, epilepsy,
etc)_____________________________________________________
_________________________________________________________
_______________________________________________________
Is there anything else we should know in order to take good care of your
child?____________________________________________________
_________________________________________________________
_______________________________________________________

Are there custody/ access orders in place that we need to be aware of?
Yes No
Copy of custody papers need to be attached to enrolment
I/We agree and acknowledge:
I have read and understood the above information

Kidspace has my permission to seek necessary urgent medical treatment at my

cost.

All care will be taken to provide supervision of children attending

the programme in accordance with programme policy and
procedures. I acknowledge however, in signing this form that
neither staff not the management of Kidspace will be liable for
any loss or damage by way of accident, injury, theft or otherwise
arising out of attending Kidspace.

Name of Parent/Caregiver:_______________________
Parent/Caregivers Signature:_____________________
Date:______
Supervisors Signature:______________________

Date:______