Booragoon Occasional Childcare Centre

525 Marmion Street Booragoon 6154

Phone : 0893161253 Fax : 0893161909
ABN: 53699009176

CCB Approval ID: OCC : 1-TH7UX

Enrolment Form
Bookings and Orientation
Orientation Visits
1st

Start Date

Regular Weekly Bookings

2nd

Date
Arrival Time
Departure Time

Finish Date

Tu W Th

Sa Su

Bef
Am
Pm
Aft

Child Details
CRN:
Surname:

Given Name:

Usual Address:

Other Names:
Suburb:

P/Code:

Telephone:
Date of Birth:

Birth Cert Shown To:

Gender Male/Female):

Is your child of Aboriginal or Torres Strait Islander origin? (Tick the appropriate boxes)
No:

Yes, Aboriginal:

Yes, Torres Strait Islander:

Lifestyle / Routine At Home

Usual getting up time:

Usual evening bed time:

Day Sleep(Approx Time):

Length:

What does your child take to bed:

Any special bedtime routines (Indicate how child is put to sleep):

On waking My Child is Often:

Happy:

Cuddly:

Sad:

Any Special Needs:

Dietary:
Behavioural:
Cultural/Religious:
Other:
Country of Birth (Mother):

(Father):

(Child):

Languages Spoken By Child:

Languages Spoken At Home:
Child's Cultural Background:
Do You Need a Bi-Lingual Worker? (Yes/No):
If Yes Why? :
Other Relatives Living With You:
Childs Siblings:
Name:

D.O.B.:

Gender (M/F):

Name:

D.O.B.:

Gender (M/F):

Name:

D.O.B.:

Gender (M/F):

Name:

D.O.B.:

Gender (M/F):

Form Revised Date: 01/03/2014

Next Review Date: 01/03/2015

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Custody of Child
Have any orders been made by any court regarding your child? Yes / No
If YES, please provide the following:
Details of Guardianship and Custody, and Terms of any specific Custody or Access provision (if applicable):

If NO, are there any disputes concerning custody of your child? Yes / No

If No Please provide details.

The Child Resides With:

Enrolling Guardian initials:

Please attach copies of relevant Court forms, documentation.

Parent / Guardian Authority To Pick Up or Drop Off / Contact in Case of Emergency
Authorised for (Tick Box)
P/U
Drop
Emer

Parent/Guardian 1:
Address:
Tel (W):

(H):

(M):

(H):

(M):

Parent/Guardian 2:
Address:
Tel (W):

1. Nominated Person (other than parent/guardian)who is authorised to consent to medical treatment of,
or to authorise administration of medication to the child if parent or guardian cannot be notified.
2. Persons Authorised To Drop Off or Pick Up Child
Name:

Relation:

Authorised for (Tick Box)

P/U
Drop
Emer

Address:
Tel (W):

(H):

Name:

(M):
Relation:

Address:
Tel (W):

(H):

Name:

(M):
Relation:

Address:
Tel (W):

(H):

Name:

(M):
Relation:

Address:
Tel (W):

(H):

Form Revised Date: 01/03/2014

Next Review Date: 01/03/2015

(M):

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Medical History
Does your child ever suffer from any of this conditions ?
Asthma:

I have obtained a Asthma / Medical Record Card from the Centre Coordinator Y/N _____
SIGNED_______________________________DATED____________

Allergies:

If Yes give details:

ADHD:

If Yes give details:

Has your child ever had any of the following?(Place a tick in the box)
Measles:

Grommets:

Breath Holding:

Mumps:
German Measles:

Chicken Pox:
Convulsions:

Others:

Does your child receive Regular Medical Attention Yes/No (if yes state details):

Side Effects (if any):

Any Additional information the Centre should be aware of :

Special Needs
Special Needs Req'd:
Agency Involved:
Contact Person:

Tel:

Paediatrician :

Tel:

Speech Therapy:
Clinic Involved:
Contact Person:

Tel:

Immunisation and Special Notes

Place a Y or a N in the box
Exempt:

12 Months:

Birth:

18 Months:

2 Months:

48 Months:

4 Months:

Chicken Pox:

6 Months:

Meningicocal C:

Other:

Special Note Regarding Healthcare:

OFFICE USE ONLY

DOCUMENTS SIGHTED Y/N_____
SIGNED___________________________________ DATED___________

Medical Emergency Authorisation

Call Ambulance: Yes

No

Medical Attention: Yes

No

Medicare No:

If no give details of
action to be taken:
St John Ambulance No:

Private Health Insurance Name and No:

Doctor's (GP) Name:
Clinic's Name:
Clinic's Address:
Telephone:

Tel(Emerg.):

Parents/Guardians are responsible for all costs incurred in medical expenses

Form Revised Date: 01/03/2014

Next Review Date: 01/03/2015

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Permissions
Do you give permission for your child to participate in outings to places of interest in close proximity to
the centre, notification of this event may not be given?
Do you give permission to apply sunscreen?
(If No, Please provide a letter absolving the centre of any Liability.)
Do you give permission to apply Insect repellent where applicable?
Do you give permission to apply Teething Gel where applicable?
Do you give permission to apply Band Aids or Sticking Plaster where applicable?
Do you give permission to apply nappy cream where applicable?
Do you give permission for your child to be transported to and from school where applicable, by Bus/Car
and you understand that your child may go to other schools first on the way to or from their school?
I have sighted the map of the routes they may travel.
Do you give permission for photos to be taken of your child?

School Attended

Phone

Teacher

Year

Start Time

Finish Time

Session 1 Start Time

Session 1 Finish Time

Session 2 Start Time

Session 2 Finish Time

Room No

Any other information regarding your child that the centre should be aware of:

I have read and understand the centres Handbook and Policies.

Signature Of Parent/Guardian:________________________________________Date:____________

Form Revised Date: 01/03/2014

Next Review Date: 01/03/2015

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