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Children’s ServicesEnrolment Form for Before and After School Care and Vacation Care

Parent and Guardian ChecklistPlease check that you have completed the following: Please check that you have completed the following:

Read and filled in every section of this form.Have you provided a copy of your child’s birth certificate?Are immunisation records attached for all Children NEW to the service?http://www.humanservices.gov.au/customer/services/medicare/medicare-online-servicesAre all Action Plans attached in regards to medical conditions?Have you attached a copy of court orders/parenting plans (if applicable)?Have you signed the Agreements section and the registration form?

Information

Locations

Peninsula Children’s ServicesPeninsula Community Centre93 McMasters Road, Woy Woy NSW 2256p: 4344 3018 or m: 0414 911 830e: [email protected]

Before and After School Care6:30 am to 9:00 am & 2:30 pm to 6:30 pm

Vacation Care7:00 am to 6:30 pm during school holidays

Gosford Children’s ServicesGosford Public SchoolBlock E, Faunce St West, Gosford NSW 2250p: 4339 9426 or m: 0451 371 713e: [email protected]


Vacation Care7:00 am to 6:30 pm during school holidays

Point Clare Children’s ServicesPoint Clare Public SchoolTakari Avenue, Point Clare NSW m: 0409 787 844e: [email protected]


Peninsula Occasional Care ServicesPeninsula Community Centre93 McMasters Road, Woy Woy NSW 2256p: 4343 1001 or m: 0435 774 288e: [email protected]

Occasional Care 8:30 am to 4:30 pm

Coast Community Connections BASC and Vacation Care Enrolment Form. Updated: 31.10.20161

mailto:[email protected]




http://www.humanservices.gov.au/customer/services/medicare/medicare-online-services

Staff Ratios Cost per session

BASC/Vacation Care 1:15 incursions (on site) 1:15 excursions 1:5 water activities

Occasional Care 1:4 0-2 year olds 1:8 2-3 year olds 1:10 3-5 year olds

Child care benefit (CCB) is available for BASC and Vacation Care so please contact the site supervisor for a quote per session.

For more information

Please refer to the Children’s Services Family Handbook

Note: Please tick check boxes or, if completing this form in Word on your computer, please double-click on check boxes and then click on “checked”

Payment OptionsPayment of full care during the vacation care period is required at time of booking. We accept bank deposit and EFTPOS. If paying by bank deposit, please see details below:

Peninsula Children’s Services Before and After School CareBSB: 032-527Account number: 257423Account name: Woy Woy Before and After School Care

Vacation CareBSB: 032-527Account Number: 257431Account name: Woy Woy Vacation Care

Gosford Children’s Services Before and After School CareBSB: 032-527Account number: 257386Account name: Gosford Before and After School Care

Gosford Vacation CareBSB: 032-527Account number: 257394Account name: Gosford Vacation Care

Point Clare Children’s Services Before and After School CareBSB: 032-527Account number: 257415Account name: Pt Clare Before and After School Care

Peninsula Occasional Care Service Occasional CareBSB: 032527 Account number: 257407Account Name: Peninsula Occasional Care

Note: Please use your child’s name as the reference so we can link it up with our records

All information contained within this document is collected for the operational purposes of Coast Community Connections Children’s Services, and shall be used solely for these purposes. Coast Community Connections protects and manages your personal information as required by the Australian National Privacy Principles, and NSW and Commonwealth Privacy Legislation.

Coast Community Connections BASC and Vacation Care Enrolment Form. Updated: 31.10.2016 2

Children’s Services Enrolment Form

All information in this form is CONFIDENTIAL

Location (Please tick which centre your child is attending)

Gosford Children’s ServicesBefore and After School CareVacation Care

Peninsula Children’s ServicesBefore and After School CareVacation Care

Point Clare Children’s ServicesBefore and After School Care

Note: Please tick check boxes or, if completing this form in Word on your computer, please double-click on check boxes and then click on “checked”.

Child 1 Child 2Name

Male/Female Male Female Male Female

Date of Birth

Age

Country of Birth

Nationality

Aboriginal/Torres Strait Islander Yes No Yes No

School attending

*CRN of Child

Parent/Guardian 1 Parent/Guardian 2Name

Address

Home Phone

Mobile Phone

Work Phone

Email address

Occupation

Employer

Country of Birth

Nationality

* DOB of Parent

* CRN of Parent* Requirements for CCB rebate. If you are claiming your child care fees on your tax you will need a CRN from

Centrelink for yourself and child(ren). You must supply your CRN number to obtain the reduced rate.


Child’s Attendance

Please write the child’s name and tick the days your child(ren) will be attending.

Mon Tues Wed Thurs Fri

Before School CareChild 1:

Child 2:

After School CareChild 1:

Child 2:

Please tick here if you only require casual care (BASC)

Vacation Care Please complete booking form

Starting date / /

If there are any changes in circumstances or days that you are requiring care, please notify us in writing to avoid any misunderstandings. It is also important if your child will be not attending on their permanent booked days to ensure we are notified as soon as possible.

Other informationAre there any court orders affecting the custody of your child?(If yes, please attach a copy for the centre’s records)

Yes No

Court orders/parenting plans:

Court order/parenting plan provided? Yes No

Does your child attend any other approved care service? Yes No

If so, for how many hours a week?

Does your child have siblings who attend other approved care services Yes No

Details:

Languages spoken at home

Please let us know if there are any religious or cultural requirements that need to be observed whilst your child is in our care

How did you hear about our service?


Emergency contacts and people authorised to collect your child

Emergency Contact 1 Emergency Contact 2

Name

Home address

Home Phone

Mobile Phone

Work Phone

Relationship to child

Emergency Contact Yes No Yes No

Authorised to Collect Yes No Yes No

Children will only be released to guardians or nominated persons over the age of 18 with photo ID as a child protection measure.

Names and dates of birth of siblingsSiblings Child 1 Child 2

Name

Date of Birth

Medical informationFamily Doctor Family Dentist

Name

Address

Phone

Other information

Child’s Medicare No

Religious or cultural requirements in case of accidents or illness

Yes No

Details:


Health InformationPlease note you will need to submit the following documents for medical conditions your child suffers.

Asthma Action Plan is required to be completed by a registered medical practitioner.

Anaphylaxis Action Plan is required to be completed by a registered medical practitioner.

Health Risk Minimisation Plan-should be finalised in consultation with the Nominated Supervisor at the service when your child commences.

Authority to administer medication form- This form authorises the staff to administer the medication as recorded on the action plan.

Child 1 Child 2Are your child’s immunisations up to date? Yes No Yes No

Please attach a copy of the immunisation record print out from the National Immunisation register

When was your child’s last tetanus injection?

Does your child suffer from any allergies? Yes No Yes No

Details

Does your child have special dietary requirements? Yes No Yes No

Details:

Does your child suffer from any medical conditions such as asthma, anaphylaxis, epilepsy, diabetes, etc

Yes No Yes No

If yes, has an action plan been provided to the service by your registered medical practitioner?

Yes No Yes No

Details:

If answering yes to anaphylaxis – please answer the following questions

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

Does your child have a auto injection device (eg EpiPen)? Yes No Yes No


Child 1 Child 2Has a health risk minimisation plan be completed by the service in consultation with you

Yes No Yes No

It is a requirement that you provide the service with an individual medical action plan for your child signed by the medical practitioner who is treating your child.

Has the anaphylaxis action plan been provided to the service Yes No Yes No

If answering yes to asthma – please answer the following questions

Has your child been diagnosed with asthma?

Yes No Yes No

Does your child require regular asthma medication?

Yes No Yes No

Has a health risk minimisation plan be completed by the service in consultation with you

Yes No Yes No

It is a requirement that you provide the service with an individual medical action plan for your child signed by the medical practitioner who is treating your child.

Additional information

Does your child have a diagnosed disability or disorder

Yes – please complete Appendix A

No

Yes – please complete Appendix A

No

Is your child on any medications? Please provide details

Yes – please complete Appendix B

No

Yes – please complete Appendix B

No

Has your child got a history of any major illness or had an operation?

Yes No Yes No

Details:

Is there any other health information staff should be aware of?

Yes No Yes No

Details:


Child 1 Child 2Are there any behaviours significant to your child that staff should be aware of?

Yes No Yes No

Details:

Is there any other information you would like to share about any special requirements, cultural or religious beliefs that the staff should be aware of?

Yes No Yes No

Details:


Agreements

Please read carefully and sign the following. Please note that unless specified these authorisations apply to all our services.

Authorisation for Paracetamol:

If my child has a temperature higher than 38° Celsius, the centre is authorised to administer the age appropriate amount of paracetamol to my child. Yes No

Signature of Parent/Guardian 1:


Authorisation for administering the centre’s asthma kit:

If my child has difficulty breathing at the centre, a First Aid qualified staff member is authorised to administer the correct dosage of Asthma medication to my child. Yes No



Authorisation for administering First Aid:

I authorise Coast Community Connections and its staff to administer first aid and first aid products as per manufactures recommendations e.g. stingoes, antiseptic creams, first aid strips.

Yes No



Immediate Medical Attention

If my child is seriously injured or ill while in care at the centre, I understand that every effort will be made to contact parents or emergency contacts. I agree that the nominated supervisor or delegate will seek urgent medical, ambulance or hospital treatment. I give permission for medical treatment for my child from a registered medical practitioner, hospital or ambulance service and will pay any costs incurred. I give permission for transportation of my child by an ambulance service. R. 161 (i) (ii).

Yes No




Permission for use of sunscreen and insect repellentI give permission for the use of sunscreen and insect repellent on my child. Yes No



ExcursionsMy child is authorised to take on routine excursions or outings away from the centre. These outings will be within walking distance of the centre, and will not cross any major roads or involve transportation. For all non-routine excursions (for example, where private and public transport may be used), separate permission will be sought. Yes No



I have read and understood all excursions on our current program. I am aware that this may consists of my child/ren walking or catching transportation e.g. car, bus, or ferry. Yes No



TravelMy child is authorised to travel by bus, car, ferry or walking as required by the program. Whilst all possible care will be the taken, Coast Community Connections and its staff will not be held responsible for any illness or accident which may occur as a result of Children’s Services’ activities.

Yes No



Fire Drills:

I authorise for my child to be taken off the premises to the emergency assembly area located on the grassed area at the back of the main car park during our fire drill practises. Yes No




Toys, games etc from homeI am aware that Coast Community Connections will not be responsible for loss, damaged or stolen electronic devices, other toys, games and swapping cards etc that children choose to bring in.

Yes No



Permission for view G and PG rated DVDsI give permission for my child to watch G and PG rated videos/DVDs. Yes No




Authorisation for Photographs and Filming

My child is authorised to be filmed or photographed for use in learning displays, documentation of the children’s work and portfolios within the centre Yes No



My child is authorised to be filmed or photographed for use on Coast Community Connections website and in centre publications and promotions. Yes No



My child is authorised to be filmed or photographed by other parents or visitorsto the centre, including students Yes No



Payment of fees

I understand that all fees must remain at least two (2) weeks in advance at all times to ensure my child’s position at the centre. Yes No



Acceptances of rules, regulations and requirements

I/we have understood and accept the rules, regulations and requirements pertaining to my child’s enrolment in this form, in the centre Handbook and Policies and Procedures folder. I understand and will abide by all the conditions appearing in this form, in the Handbook or in any documentation, as amended by the centre. I declare that the information given above is accurate and agree to notify the centre immediately, in writing, if there are any changes to the above information

Yes No

Name of Parent/Guardian 1:

Signature:

Date / /

Name of Parent/Guardian 2:

Signature

Date / /


Photograph of your child

Please provide a small photo of your child if this is their first time at Before and After School Care/Vacation Care.

Child 1 Child 2


Appendix A

Please complete if your child has a diagnosed disability or disorder

Child 1 Child 2

Child’s name

Date of Birth

Does your child receive ISS funding?

Yes No Yes No

Diagnosis:Please provide a copy of the report from your child’s doctor and complete “Additional Enrolment Information” form

Any other relevant information:

Appendix BPlease complete if your child is on any medications

Child 1 Child 2

Child’s name

Date

Medication Required

Please provide details including possible side effects.

Please note: an “Authority to administer medication” form will be required to be completed.

Appendix C: Vacation Care Booking FormPlease complete separate booking form available on our website or from our service: http://www.coastcommunityconnections.com.au/children-s-services


http://www.coastcommunityconnections.com.au/children-s-services

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