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Child Enrolment Form
Child Enrolment Form
Child Enrolment Form
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. Licensed childrens services may use this form to collect the childs enrolment information as required in regulations 31 to35. Questions marked with an asterisk * are not required by the regulations, but you are encouraged to answer these to assist the service in
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)
Parent/Guardian Information
Mother Name: Address-as per child or: Name: Address-as per child or: Father
Telephone/s (H)
Telephone/s (H)
Does the child live with the mother? No Yes (please tick) Occupation: Guardian Name: Address-as per child or: Telephone/s (H) (Mobile Does the child live with this guardian?
Does the child live with the father? No Yes (please tick) Occupation: Guardian Name: Address-as per child or: Telephone/s (H) (Mobile 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, the work / 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
Name: Address:
Name: Address:
Telephone/s (H)
Telephone/s (H)
Bring the original court order/s for staff to see and a copy to attach to this enrolment form: 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 Community Home Based Educators 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, b) give these powers to someone else, AND/OR
2. If these orders:
Please describe these changes and provide the contact details of any person given these powers: ..
Name of Doctor/Medical Service:Telephone: Address of Doctor/Medical Service: Does your child have a health record? If yes, please provide to Kids Community for sighting. Child health record means a record that documents 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:
Does your child have any special need? to the special need.
No
Yes
(please stick )
If Yes, please provide details of any special needs and any management procedures to be followed with respect 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? Does your child have an auto injection device (eg Epipen)? Has the Anaphylaxis Action Plan been provided to Kids Community? Has a risk management plan been completed by Kids Community consultation with you? No No No No Yes Yes Yes Yes
In the case of anaphylaxis you will be provided with a copy of the Kids Community anaphylaxis management policy. You will be required to provide Kids Community with 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.
Birth
2months
4months
6months
12months
18months
4months
Additional immunisations for Aboriginal and Torres Strait Islander children (if required)
12 - 24 months
18 - 24 months
*Other Information
If there is anything else that Kids Community should know about the child? (e.g. excessive fear, favorite activities, attending other early childhood service or early intervention service, etc)
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 Community to seek medical treatment for the child from a medical practitioner, hospital or ambulance service. Parent Name.ParentSignature.. Date//20
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 not affected 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 the Childrens 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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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
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 not affected 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 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 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. 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 this Enrolment Form including items 1 to 17 above, and any other policies and procedures advised by the centre either directly or by making them available for perusal at the Centre.
Signature of Primary Parent/Guardian: ___________________________________Date: ________ Signature of Secondary Parent/Guardian): ________________________________Date: ________
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Please circle the type of care you require: Permanent Days requiring care: Monday Tuesday Wednesday Thursday Friday Saturday Sunday
From:To: From:To: From:To: From:To: From:To: From:To: From:To:
Casual
B/A School
School Holiday
I agree to pay fees for the days that I have chosen above. I understand whether I use or not will be charged for my chosen 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 Child Care Benefit (CCB) applied to your child care fees, you must contact Centrelink to confirm that they have the correct name 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 enable you 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 same information. 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 until the details are corrected with Centrelink. Name: _______________________________ Signature: _________________________________ Date: _____________________
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