Enrolment Form

Please fill in all required details below as accurately as possible to ensure your childs placement confirmation is not delayed.

Child's Details

Last Name *

Given Name *

Sex *

CRN:

Date of Birth *

Place of Birth *

Upload birth certificate or other documents *

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Ethnicity

Languages Spoken

Address *

Medicare Number *

Names and ages of other children living at home

Names of other adults living at home

We welcome family participation in our programs. Are there any skills you would like to volunteer e.g. sewing, reading stories, etc

Are there any special religious or cultural considerations you would like us to know about?

Please use this space for any other comments or information you would like us to know about your child and your family

Parent 1 Details

Parent 2 Details

Name of Parent 1 *

Name of Parent 2 *

Phone Number of Parent 1 *

Phone Number of Parent 2

Home Address of Parent 1 *

Home Address of Parent 2 *

Email Address of Parent 1 *

Email Address of Parent 2 *

Date of Birth of Parent 1 *

Date of Birth of Parent 2 *

Relationship of Parent 1 to child *

Relationship of Parent 2 to child *

Ethnicity of Parent 1

Ethnicity of Parent 2

Language Spoken of Parent 1

Language Spoken of Parent 2

Occupation of Parent 1

Occupation of Parent 2

Company/Employer Name of Parent 1

Company/Employer of Parent 2

Work Address of Parent 1

Work Address of Parent 2

Work Phone Number of Parent 1

Work Phone Number of Parent 2

Health Fund Number of Parent 1

Health Fund Number of Parent 2

Customer Reference Number (CRN) of Parent 1

Customer Reference Number (CRN) of Parent 2

Days of Attendance

Start Date *

Health

Has your child been immunised? *

NoYes

Are your child's immunisations up to date? *

NoYes

Please upload a copy of your child's Immunisation Schedule as posted on the Medicare Website *

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If NO, please provide medical reasons from an authorised medical professional

Please provide details of child's:

Doctor's Name

Dentist Name

Doctor's Address

Dentist's Address

Doctor's Phone Number

Dentist's Phone Number

Does your child:

Have allergic reactions e.g. food, medicine, grass, bees, face paint, sun creams, soap

Have or is at risk of having asthma?

Have or is at risk of having a anaphylactic reaction?

Have any behaviour difficulties we should know about?

Regularly visit a specialist e.g. speech therapist?

Have a special medical condition?

Take any regular medications?

Please provide a medical management plan for any of the above

Current health status of child

Upload Medical Management Plan (if applicable)

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Eating

Special dietary needs e.g. vegetarian, religious beliefs, allergies etc.

Any food likes

Any food dislikes

General Information

Are there special festivals and celebrations in your family? *

NoYes

If yes, pleases give details

Are there any words we need to know in another language to help make your child's day smoother?

Does your child have any special comforter?

Does your child have any fears? e.g. thunder, animals etc

Does your child have any special needs you would like us to know about?

Please provide at least two (preferably local) contacts who are over 18 years of age and have your authority to pick up your child from the centre. Please indicate which of these contacts also have your authority to:

Collect your child from the centre
Be contacted by staff in case of an emergency
Authorise medical treatment or administering of medication if contacted by staff

Contact 1

First Name - Contact 1 *

Last Name - Contact 1 *

Date of Birth - Contact Person 1 *

Home Phone - Contact 1

Work Phone - Contact 1

Mobile - Contact 1 *

Address - Contact 1 *

Relationship to Child *

Authority to Collect *

NoYes

Authority to be contacted in an emergency *

NoYes

Medical Authority *

NoYes

Contact 2

First Name - Contact 2 *

Last Name - Contact 2 *

Date of Birth - Contact Person 2 *

Home Phone - Contact 2

Work Phone - Contact 2

Mobile - Contact 2 *

Address - Contact 2 *

Relationship to Child - Contact 2 *

Authority to Collect - Contact 2 *

NoYes

Authority to be contacted in an emergency - Contact 2 *

NoYes

Medical Authority - Contact 2 *

NoYes

The staff will not allow your child to go with adults unless their names are written on this form. All adults will be asked to produce photo identification at the time of collecting your child.

Court Orders

Are there any Court Orders or pending Family Court hearings that impact your child? *

NoYes

If yes, please provide details

Are there any Parenting Orders or pending Mediation hearings that impact your child? *

NoYes

Please provide details

Please provide JP certified copy of the Court Orders or Parenting Orders

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Permissions and Conditions of Enrolment

THIS ENROLMENT FORM MUST BE COMPLETED AND SIGNED BEFORE YOUR CHILD CAN COMMENCE AT OUR CENTRE

I agree to abide by the Centre Policies and Procedures, in the Parent Information and Centre Policy books. *

I have read and understood all Permissions and Conditions set out in this Enrolment Form. I certify that the information supplied is true and correct to the best of my knowledge.

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