Enrolment Form

The enrolment form is required to be returned and an orientation attended to at the service within 7 days to secure the offered day of enrolment.

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SGOOSH ENROLMENT FORM

Please contact the service if you require assistance in completing this form.

For each child please complete a separate Medical Information Form which includes, medical information, immunisation details & developmental information.

CHILDREN'S DETAILS :

CHILD 1

First Name :(*)

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CHILD's Centrelink Reference Number (CRN)
Please note: Parent and child have their own individual CRN number(*)

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Family Name:(*)

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MaleFemale Invalid Input

DOB:(*)

/ / Invalid Input

CHILD 2

First Name:

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CHILD's Centrelink Reference Number (CRN)
Please note: Parent and child have their own individual CRN number

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Family Name:

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MaleFemale Invalid Input

DOB

/ / Invalid Input

CHILD 3

First Name:

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CHILD's Centrelink Reference Number (CRN)
Please note: Parent and child have their own individual CRN number

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Family Name:

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MaleFemale Invalid Input

DOB:

/ / Invalid Input

CHILD 4

First Name:

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CHILD's Centrelink Reference Number (CRN)
Please note: Parent and child have their own individual CRN number

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Family Name:

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MaleFemale Invalid Input

DOB:

/ / Invalid Input

Child/ren's home address:(*)

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DAYS OF ATTENDANCE (Please Tick) :

Please indicate the days of attendance (Before School Care – 7.00am to 8.55am, After School Care - 2.55pm to 6.00pm)

Before School Care

MONDAYTUESDAYWEDNESDAYTHURSDAYFRIDAY Invalid Input

After School Care

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Child/ren's Start Date:(*)

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Year Group:

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Where do you collect your child/ren from when not attending OOSH?

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CULTURAL CONSIDERATION :

Education and Care Services National Regulations - Regulation 160 (f, g, h)

Languages spoken at home:

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Ethnicity:

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Country of Birth:

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Religion:

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Is the Child/ren of Aboriginal or Torres Strait Islander Descent?

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Please outline any practices, cultural, religious celebrations or dietary restrictions you would like followed:

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Please outline any religious practices you would like followed including religious celebrations:

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Would you like to share aspects of your cultural heritage with the service? Please complete the cultural heritage form included in the enrolment pack?

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(Please note - for multiple children you will be directed to complete separate Medical Information Forms for each child at the end of this form)

MEDICAL INFORMATION CHILD 1:

Education and Care Services National Regulations - Regulation 160 (3a, I, j)

Please outline any dietary restrictions?
A dietary form will be issued by the service and further discussion

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Does your child have any specific health care needs or conditions?(*)

YesNo

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Please Select

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Allergies?(*)

YesNo

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Has a doctor diagnosed this allergy?(*)

YesNo

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Please provide details of your child's allergies. These can include insect stings, medication, food, animals, latex or other.

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If yes, a copy of the service’s Medical Conditions Policy will be provided, Individual Medical Management Plan, Risk Management and Communication Plan to be completed in consultation with educators medical practitioners, parent/guardian.
(it is best practice for parents/guardians to consult with the child’s registered medical practitioner in the development of this plan)

The plan should include:

A photo of the child
If relevant, state what triggers the medical condition, asthma, allergy or anaphylaxis
First aid needed
Contact details of the doctor who signed the plan
When the plan should be reviewed

Anaphylaxis/Allergy Action plans to be completed by a Medical Practitioner on the ASCIA template form.

Please provide details below

Name of medical specialist:

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Address:

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Phone contact:

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If your child has diagnosed allergies or anaphylaxis please supply medication as outlined on your child’s management plan & ensure the form is accurate and signed by a medical practitioner.

Asthma

Does your child take regular Asthma medication?(*)

YesNo

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If yes, please provide details:

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A Child’s Asthma Record will need to be completed to identify standard asthma first aid plan or a copy of the formal asthma plan.
Please supply an inhaler spacer and prescribed medication/Ventolin as outlined on your child’s management plan.

MEDICATION AGREEMENT

Medication will only be administered if it is in the expiry or use by date, original packaging, labelled and instructions that can be clearly read. The service medication form must be completed by the parent/guardian for medication to be administered by staff. Additionally, if the medication has been prescribed by a medical practitioner:

The label must contain the child’s name
Parent/Guardian must provide any verbal or written instructions provided by the medical practitioner.

Parent/Guardian 1
Signature:(*)

Sign Above

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Parent/Guardian 2
Signature:

Sign Above

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*Do you authorise the Nominated Supervisor or another educator at the service to seek medical treatment from a registered medical practitioner, hospital or ambulance service?(*)

YesNo

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Parent/Guardian 1
Signature:(*)

Sign Above

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Parent/Guardian 2
Signature:

Sign Above

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*Do you authorise the Nominated Supervisor or other educator at the service to seek dental treatment from a registered dental practitioner or service in the event of an emergency?(*)

YesNo

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Parent/Guardian 1
Signature:(*)

Sign Above

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Parent/Guardian 2
Signature:

Sign Above

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Child’s Registered Medical Practitioner or Service Details:

Medicare Number:(*)

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Medicare Expiry Date:(*)

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Private Health Fund Name:

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Ambulance Cover:(*)

YesNo

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Service Name:(*)

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Practitioner’s Name:(*)

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Practitioner’s/Medical Service Address:(*)

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Contact Numbers:(*)

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Child's Dentist Details

Service Name:

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Practitioner Name:

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Practitioner’s/medical Service Address:

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Contact Number:

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IMMUNISATION DETAILS/HEALTH: CHILD 1

Are your child’s immunisations up to date?(*)

YesNo

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Please provide a copy of your child's: Immunisation History Statement

I have chosen not to have my child immunised. A copy of our immunisation policy will be issued. Invalid Input

Please sign:(*)

Sign Above

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Do you authorise the Nominated Supervisor or other educator to transport the child in an ambulance in the event of an emergency?(*)

YesNo

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Parent/Guardian 1
Signature:(*)

Sign Above

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Parent/Guardian 2
Signature:

Sign Above

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Please be advised that if the child is diagnosed with asthma or anaphylaxis and an emergency occurs, the Responsible Person or educators may administer emergency first aid without making contact. Educators will notify the child’s parents and/or emergency services as soon as possible.(*)

YesNo

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Parent/Guardian 1
Signature:(*)

Sign Above

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Parent/Guardian 2
Signature:

Sign Above

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DEVELOPMENTAL INFORMATION CHILD 1:

Does your child have any difficulties with hearing, sight or speech?(*)

YesNo

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Please provide details:

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Does your child have a physical disability or delay, including intellectual, sensory or physical impairment?(*)

YesNo

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Please provide details:

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Provide us with any other information we should know about your child. Please assist your child to complete the About You form which will provide our educators with further information on your child’s interest. (e.g favourite family activities, free time, strengths etc.)

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STAYING IN BOUNDS: CHILD 1:

We have expectations that children will be responsible and stay in the designated areas within the school grounds.
Each session (morning/afternoon) children are informed by staff educators which areas are open.
If families have concerns with their child wandering and going out of bounds please discuss with us.

Are you confident your child can follow these guidelines?(*)

YesNo

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If no, please discuss with the Centre Manager/Nominated Supervisor

FAMILY INFORMATION

Does your child have any siblings? If so, please provide their names and ages.

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Does your child have any other close relations attending the service? E.g. cousins, neighbours, close friends. If so, please provide their names and ages.

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PRIMARY PARENT/GUARDIAN

Education and Care Services National Regulations - Regulation 160 (3b)

Parent/Guardian Name:(*)

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Parent/Guardian Surname:(*)

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DOB:(*)

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Home Phone Number:(*)

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Home Address:(*)

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Mobile Number:(*)

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Parent Guardian Email(*)

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Work Number:

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Relationship to Child/ren:(*)

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Parent Centrelink Reference Number (CRN):(*)

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Employment status: (Please select)(*)

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Country of Birth:(*)

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Place of employment:(*)

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Occupation:(*)

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Hours of work:

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Is there a second parent/guardian?(*)

YesNo

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SECONDARY PARENT/GUARDIAN

*This must be completed, unless you are a single parent/guardian family

Parent/Guardian 2 Name:(*)

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Parent/Guardian Surname:(*)

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DOB:(*)

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Home Phone Number:(*)

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Home Address:(*)

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Mobile Number:(*)

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Parent Guardian Email(*)

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Work Number:

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Relationship to Child/ren:(*)

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Parent Centrelink Reference Number (CRN):(*)

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Employment status: (Please select)(*)

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Country of Birth:(*)

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Place of employment:(*)

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Occupation:(*)

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Hours of work:

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COURT ORDER

Education and Care Services National Regulations - Regulation 160 (3c, d)

Are there any court orders, parenting orders or parenting plans relating to the powers, duties and responsibilities or authorities of any person in relation to the child/ren or access to the child/ren? *

YesNo

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If yes, please provide all relevant documentation and paperwork

Are there any other court orders relating to the child/rens residence or the child/rens contact with a parent or other person? Have photographs and names of unauthorised people been attatched to this form? *

YesNo

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If yes, please provide all relevant documentation and paperwork

Please note that without this documentation we cannot legally enforce the order/s
please note all authorised contacts must use their own mobile phone number and pin code when signing in and out.

FIRST EMERGENCY CONTACT (THIS IS MANDATORY TO OBTAIN ENROLMENT)

Education and Care Services National Regulations - Regulation 160 (3b, ii, iii, iv, v) 161 (1a, I, ii, 1b)

There may be times or situations where your child/ren has had an accident, injury, trauma or illness and Parent/guardians cannot be reached or are unable to collect their child/ren.
To deal with these circumstances and in case of an emergency the service will inform the following person to collect and care for the child/ren.
This person must live a maximum of 30 minutes from the service and must provide identification when collecting the child/ren.
Please obtain the person’s consent before listing them as an emergency contact.

Full Name:(*)

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Relationship to Child/ren:(*)

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Address:(*)

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Home Phone:(*)

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Mobile Phone:(*)

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Work Phone:(*)

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Can this person be contacted to give consent for medical treatment or to authorise for a Responsible Person or educator to administer medication to the child/ren in the event that you cannot be contacted?(*)

YesNo

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Can this person be contacted to give consent for educators to take the child/ren outside the service’s premises in the event that you cannot be contacted?(*)

YesNo

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Can this person be contacted to give consent to the transportation of the child/ren by an ambulance service?(*)

YesNo

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Can this person give authorisation for the service to take the child/ren on regular outings?(*)

YesNo

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I agree to the above - Parent/Guardian 1 Signature:(*)

Sign Above

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SECOND EMERGENCY CONTACT

Full Name:(*)

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Relationship to Child/ren:(*)

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Address:(*)

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Home Phone:(*)

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Mobile Phone:(*)

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Work Phone:(*)

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YesNo

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Can this person be contacted to give consent for educators to take the child/ren outside the service’s premises in the event that you cannot be contacted?(*)

YesNo

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Can this person be contacted to give consent to the transportation of the child/ren by an ambulance service?(*)

YesNo

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Can this person give authorisation for the service to take the child/ren on regular outings?(*)

YesNo

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I agree to the above - Parent/Guardian 1 Signature:(*)

Sign Above

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CHILD CARE SUBSIDY (CCS)

Child Care Subsidy will be paid directly to the service to reduce the fees families pay. To claim Child Care Subsidy (CCS) families must meet eligibility requirements which include:

1. You and/or your partner must care for your child at least 2 nights per fortnight or have 14% care?(*)

YesNo

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2. Are you liable for fees for care provided at an approved child care service?(*)

YesNo

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3. Do you meet residency requirements?(*)

YesNo

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4. Does your child/ren meet immunisation requirements?(*)

YesNo

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5. Have you completed the Child Care Subsidy assessment on the myGov website?(*)

YesNo

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6. Have you received confirmation about your Child Care Subsidy?(*)

YesNo

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If you need assistance with completing this form please speak to the Centre Manager who will be happy to assist you. Please ensure that if any details change, you notify the service immediately.

ENROLMENT AGREEMENT

Please read the following agreement carefully before signing. If you have any questions please speak with the Service Manager. Please tick the following items to authorise:

HEALTH & SAFETY

I/We give permission for our child/ren to:

Participate in outings to places of interest (permission slip will have to be signed before allowing your child/ren to leave the service)(*)

YesNo

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SPF50 sunscreen applied prior to sun exposure (If not, please provide a letter releasing the service of any liability). Service currently uses Ombra brand (ALDI) or Cancer Council brands between the hours of 3 -5.30pm(*)

YesNo

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We will supply our child/ren with their own sunscreen(*)

YesNo

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Insect Repellent (Aerogard) applied when necessary(*)

YesNo

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PHOTOGRAPHY & VIDEO:

I/We give permission for our child/ren to:

For photos/artwork to be displayed on the service walls/noticeboards/service DIGITAL photo frame(*)

YesNo

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December 2020 9 For photographs of my child/ren taken by educators may be displayed or viewed at the service or incorporated into other children’s programming related documentation.(*)

YesNo

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For photos to be included in the monthly service newsletters that is emailed to OOSH families(*)

YesNo

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Samuel Gilbert OOSH Families Facebook page (closed)(*)

YesNo

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For photos of my/our child to be used on the service website www.sgoosh.com or used in organisation’s resources/flyers. (individual permission will be sought for external publications)(*)

YesNo

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For my child to watch G rated videos/DVDs(*)

YesNo

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For my child to watch PG rated videos/DVDs(*)

YesNo

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WRITTEN AGREEMENT:

Service and Parent/Guardian must agree up-front on the arrangements for the care of a child. Arrangements must be recorded and kept up to date to ensure compliance. A change of days form must be completed when altering sessions of care.

Complying Written Arrangement

CWA

A CWA is an enrolment type used for families wishing to claim CCS now or in the future

Relevant Arrangement

An RA is an enrolment type used for families not wishing to claim CCS

Additional Child Care Subsidy

ACCS

ACCS is used when a child care provider identifies that a child is at risk of serious abuse or neglect but there is no individual identifies to pay the child care fees

Arrangement with an organisation

Arrangement with an organisation is liable for the fees for the care of the child

This Written Arrangement between, Parent/Guardian Full Name(*)

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and Samuel Gilbert Out of School Hours Care Centre Inc. is an ongoing agreement between the Service provider and the Parent/Guardian, to provide care in return for fees. The Written Arrangement must contain a minimum amount of information set out in subsection 200B (3) of the Family Assistance Administration Act. Claimant registering or registered for Child Care Subsidy to complete.

Arrangement Type (Please Select):(*)

CWARAACCSArrangement with an organisation

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Name of Service: Samuel Gilbert Out of School Hours Child Care Inc

Service ID: 19000734V

Parent/Guardian Full Name:(*)

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Parent/Guardian Contact Details:(*)

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Parent/ Guardian CRN:(*)

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Parent/Guardian Date of Birth:(*)

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Date the arrangement was entered:(*)

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Full name of child/ren attending care:(*)

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Child’s Date of Birth:(*)

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Child CRN:(*)

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Expected session of care (Please Tick):

Before School Care

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After School Care

MONDAYTUESDAYWEDNESDAYTHURSDAYFRIDAY Invalid Input

Care Arrangement:

Routine CareCasual CareFlexible Care Invalid Input

Fees to be charged to the individual for the sessions of care provided:

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Please tick the box to confirm you have read each point:

I agree to inform the service in writing immediately of any changes to the information included in this enrolment form.

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I agree to inform the service in writing immediately of any changes to information included within the complying written arrangement form.

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I agree to inform the service of any changes to information included in this enrolment form including individual medical needs

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I agree to pay the service enrolment fee and am aware that the enrolment fee is non-refundable. $25.00 single child / family enrolment $40.00. This fee will be applied to your first account.

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I agree to ensure my fees are paid up to date and understand that my child/ren’s position at the service will be in jeopardy if my fees are not kept up-to-date. I understand that all booked days are paid for even when my child is absent due to sickness or on holidays. Public holidays falling in school terms are invoiced

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If I am unable to collect my child by closing time I will contact the service and organise for one of the persons listed as authorised contacts to collect my child prior to closing time. I am aware that if my child/ren have not been collected by closing time, and if I am unable to be contacted, those persons nominated as authorised contacts will be called by service staff educators to collect my child/ren.

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I agree to pay all fees in relation to the care of my child/ren and or late penalties in relation to fees, late pickups and non-notification of absence. Please see the Service handbook www.sgoosh.com for these fee penalties

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I agree to giving two weeks written notice in writing to withdraw my child/ren or reduce scheduled days and will complete the appropriate form/change of days/exit questionnaire available on the service website and within the service

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I give permission for prescribed medication to be administered by service primary contact staff upon my authorisation on the service’s medication form. I understand that if details are filled in incorrectly or left blank or if the medication does not meet the standards of the service’s policy the medication will not be given unless, in the case of missing or incorrect details I can be contacted to authorise the missing details. I agree to inform the staff both verbally and in writing of the need for medication for my child. I understand that non-prescription medication will not be given by staff unless it is accompanied by a current (within 6 months) dated Doctors letter stating the name of and reasons for the medication and only then if the Centre Manager deems the child/ren well enough to attend the service.

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I give permission for my child/ren to be observed by the Educators of the service and tertiary students supervised by the Educators. I give permission for my child/ren to participate in programs organised by tertiary students under the supervision of an Educator. I am aware that confidentiality is always respected and that students will not be left with children without an Educator present.

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I have read the service handbook and am familiar with the Service’s Policy Manual located in the sign in/out area and on the service website.

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Would you like a hard copy of the handbook ? Please Select(*)

YesNo

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I agree to follow, support and abide by these policies and am aware that educators are available to discuss any policies that I do not fully understand. I know that if I have any concerns, suggestions or compliments that I can make these in person to an educator, via email or anonymously in the suggestion box. Member feedback forms are available in the pigeon hole near the sign in/out area or on our website. (And issued on enrolment)

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I am interested in being involved in the services voluntary Management Committee. Meetings are held twice per term where we discuss the overall management and general operation of the service. The Annual General Meeting is usually held in March. As this service is a not for profit organisation we rely heavily on the support of our members. I will attend the Annual General Meeting of this service Invalid Input

I, or someone I know has a skill they could share with the children, staff or service eg. Cultural, Human Resources, reviewing policies, Information and technology, craft, cooking, gardening, general maintenance etc. Invalid Input

Signed:(*)

Sign Above

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Name:(*)

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Date:(*)

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ATTACHED DOCUMENTS:

Please ensure ALL of the following documents are attached to this application before submission:

Parent CRN & date of birth of who is registered to claim the Childcare subsidy (please ensure this is correct) Invalid Input

Immunisation Record Invalid Input

CWA Arrangement Form completed & signed Invalid Input

About You form completed Invalid Input

Child/ren’s CRN number/s & Date of birth (please ensure this information is correct) Invalid Input

Medical document eg asthma plan, anaphylaxis, allergy individual health care plan, risk minimisation & communication form, dietary form & equipment required to support your childs health needs Invalid Input

Child Care Subsidy Confirmation eg. MyGov registration YOU WILL BE INFORMED ABOUT THIS PROCESS AT THE SERVICE ORIENTATION Invalid Input

FURTHER INFORMATION:

Name of the early childhood service your child is coming from?

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PRIVACY DISCLAIMER

We acknowledge and respect the privacy of its clients. The enrolment information that is collected assists us to meet our legislative obligations and to provide the best level of education and care for your child. By completing this form, you have consented to this information being collected. The information will be used by educators/staff members and relevant government authorities. You have the right to access and alter personal information concerning yourself or your child in accordance with the Privacy Act 1988 and our Privacy and Confidentiality Policy.