ENROLMENT FORM NSW WITH PREFERRED DATES

CHILD DETAILS

Surname	___________________________________________________________________________
Given names	___________________________________________________________________________
Preferred name	___________________________________________________________________________
Home address	___________________________________________________________________________

Suburb _____________________________________________

Postcode ________________

Gender Male Female Date of birth ____/____ /_______

* Please provide a copy of your child’s birth certificate

What is your child’s cultural background?_____________________________________________________________

Please advise us of any cultural or religious practices you would like us to follow

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

Is your child of aboriginal or Torres Strait Islander descent? Yes No

What language is spoken at home? ______________________________________________________________

Child’s CRN ______________________________________________________________

If your child has siblings, please advise their names and ages.

_______________________________________________________________________________________________

Please provide us with any other information we should know about your child (eg favourite activities,

fears, routines, strengths, special words (please translate if applicable)), toileting and sleeping practices etc)

_______________________________________________________________________________________________

(Optional) If your child is going to school next year, please advise the name of the school.
_______________________________________________________________________________________________
(Optional) Do you authorise the service to exchange information with the school to assist your child’s transition to school?

Parent One	Yes	Yes	Signature	________________________________
Parent Two	No	No	Signature	________________________________

PARENT DETAILS

MEDICAL INFORMATION

Medicare Number __________________________ Do you have ambulance cover? Yes No

Private Health Fund Yes No Fund name ___________________ Fund Number ________________

Doctor’s Name Doctor’s phone number

______________________________________________ ____________________________________

Doctor’s address

_______________________________________________________________________________________________

(Optional) Dentist’s Name (Optional) Dentist’s phone number

______________________________________________ ____________________________________

(Optional) Dentist’s address

_______________________________________________________________________________________________

Immunisations

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

* Please provide a copy of your child’s Australian Childhood Immunisation Records (ACIR) Statement. (You can get a copy by calling 1800 653 809, by email on acir@medicareaustralia.gov.au , from a Medicare or Centrelink office or online at www.medicareaustralia.gov.au/online ).

If your child’s immunisations are not up to date, please attach one of the following documents:

A current ACIR Immunisation History Form on which the doctor has certified the child is on an approved catch-up schedule

An ACIR Immunisation Exemption – Medical Contraindication Form signed by a doctor

Specific Health Care Needs

Does your child have any specific health care needs or medical conditions eg asthma, allergies, anaphylaxis, diabetes? Yes No

If yes, please provide details

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

* If yes, please provide a Medical Management Plan for your child (these are prepared by and signed by the child’s doctor). The Plan should cover what triggers the medical condition or allergy, first aid needed, doctor’s contact details, plan review date and include a photo of your child. We will then develop a risk minimisation plan to reduce the possible incidence of triggers in consultation with you.

Office use only: Child’s health record sighted Yes Details __________________________________________

Medical Conditions Policy provided to parents if child has identified medical condition/health care need. Yes

DIET

Does your child have any dietary restrictions that you have not already mentioned? Yes No

ADDITIONAL NEEDS

Has your child been diagnosed with any special needs or learning difficulties? Yes No
If yes, please provide details

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

AUTHORISATIONS AND EMERGENCY CONTACTS

Do you authorise the Approved Provider, Nominated Supervisor or an educator to seek medical treatment for your child from a registered medical practitioner (includes dentist), hospital or ambulance service, and/or to transport your child by ambulance in an emergency?

Parent 1 Yes Signature________________________________________________

Parent 2 Yes Signature________________________________________________

You may authorise another person to collect your child from the service. If your child needs to be collected because they are unwell, we will contact this person if we cannot contact you or you are unable to collect your child. This person must therefore live a maximum of 30 minutes from the service and must provide identification when collecting the child. Please obtain their consent before listing them as an emergency contact.

Contact One

Name	___________________________________________________________________________
Relationship to child	___________________________________________________________________________
Home phone	Work phone Mobile
____________________	____________________ ____________________
Address	___________________________________________________________________________
Email	___________________________________________________________________________
Contact’s Signature	___________________________________________________________________________

Parent One

I authorise this person to collect my child from your service	Yes	No
Can we notify this person of any emergency involving your child if we cannot immediately contact you?	Yes	No
Can this person consent to medical treatment or the administration	Yes	No
of medication if we cannot contact you?
Can this person consent to the Nominated Supervisor or an educator	Yes	No
taking the child outside the service if we cannot contact you?

Parent One Signature _________________________________________

Parent Two

I authorise this person to collect my child from your service	Yes	No
Can we notify this person of any emergency involving your child if we cannot immediately contact you?	Yes	No
Can this person consent to medical treatment or the administration	Yes	No
of medication if we cannot contact you?
Can this person consent to the Nominated Supervisor or an educator	Yes	No
taking the child outside the service if we cannot contact you?

Parent Two Signature _________________________________________

Contact Two

Name	___________________________________________________________________________
Relationship to child	___________________________________________________________________________
Home phone	Work phone Mobile
____________________	____________________ ____________________
Address	___________________________________________________________________________
Email	___________________________________________________________________________
Contact’s Signature	___________________________________________________________________________

Parent One

I authorise this person to collect my child from your service	Yes	No
Can we notify this person of any emergency involving your child if we cannot immediately contact you?	Yes	No
Can this person consent to medical treatment or the administration	Yes	No
of medication if we cannot contact you?
Can this person consent to the Nominated Supervisor or an educator	Yes	No
taking the child outside the service if we cannot contact you?

Parent One Signature _________________________________________

Parent Two

I authorise this person to collect my child from your service	Yes	No
Can we notify this person of any emergency involving your child if we cannot immediately contact you?	Yes	No
Can this person consent to medical treatment or the administration	Yes	No
of medication if we cannot contact you?
Can this person consent to the Nominated Supervisor or an educator	Yes	No
taking the child outside the service if we cannot contact you?

Parent Two Signature _________________________________________

COURT ORDERS

Are there any court orders, parenting orders or parenting plans covering the powers, duties, responsibilities or authorities of any person in relation to the child or access to the child, or relating to the child’s residence or contact with a parent or other person?

Yes (please attach) No

PHOTOGRAPHY

I consent to:

my child being photographed by educators and staff members at the Service for educational purposes or to support their medical documentation
my child being photographed by other individuals using the Service including school photographers, individuals undertaking research projects and students on practicum placements.
the photographs taken by educators and staff members being used to publicise the Service or to inform Service families about what is happening at the Service. This may include posting the photographs on our Service website or including them in Service brochures and media articles.

the photographs taken by Researchers and students being used to support their research project or student placement. This may include publishing the photo in journal articles, reports or conference papers and assignments.

the posting of photographs taken by educators and staff members on the Service’s social media account in a closed group

I understand I can withdraw my consent about the taking of photographs of my child at any time by advising the Nominated Supervisor in writing.

Parent One Yes No Signature____________________________________________

Parent Two Yes No Signature____________________________________________

REGULAR OUTINGS

We may undertake regular outings to places eg the park or post office. Before the first outing, we will obtain your authorisation, outlining all relevant details and risks involved. If the risks do not change for subsequent outings to the same venue over the next 12 months, do you authorise the Nominated Supervisor or educators at the service to take your child on the regular outing?

Parent One Yes No Signature____________________________________________

Parent Two Yes No Signature____________________________________________

DECLARATION

As a person who has parental responsibility for the child referred to in this enrolment form for <INSERT SERVICE NAME> I:

declare that the information in this enrolment form is true and correct and I will immediately inform the

service in the event of any change to this information

understand there may be costs involved in the provision of professional medical, ambulance or hospital services to

my child as a result of a medical emergency or accident at the service, and I agree to pay those costs

agree to collect or make arrangements for the collection of my child if he/she becomes unwell at the service
will not send my child to the service if he/she is sick/unwell
understand my child must have any required medication (including Epipen) with them at the service at all times

or they will be unable to attend

understand and agree that a first aid trained staff member may administer first aid when necessary
declare that I have read and understood the Code of Conduct and policies of < INSERT SERVICE NAME> and will abide by them. These policies include the Medical Conditions Policy, Administration of Authorised Medication Policy, Delivery and Collection of Children Policy, Infectious Disease Policy, Immunisation Policy, Behaviour Guidance Policy (in Relationships with Children Policy) and Privacy and Confidentiality Policy
have read and will comply with the fees and payment structure of <INSERT SERVICE NAME>
agree to update any information relating to my emergency contacts, the people I have authorised to collect my child, and my child’s medical or dental professionals (including their contact details)
agree to provide updated information about my child’s immunisations whenever he or she is vaccinated
agree that my child’s place at the service is subject to the Priority of Access scheme as outlined in the Enrolment Policy
agree for my child to be observed and programmed for by students who may be employed at the service or completing practical components of their studies at the service, and if relevant, copies of the child’s documentation to be submitted to the institution the student is completing their studies at as part of an assessment
agree to provide information about my child’s life, family and community to support the achievement of meaningful learning outcomes
understand that the Nominated Supervisor may suspend or terminate my child’s place at the service if he/she feels that the safety or wellbeing of any child or staff member at the service is compromised by my child or a family member
understand that the service takes all care but no responsibility for the loss or damage to children’s personal belongings and clothing

Parent One Signature _________________________________ Date ___________________________

Parent Two Signature _________________________________ Date ___________________________

Which days you would like your child to attend?

Monday	Tuesday	Wednesday	Thursday	Friday

Proposed start date _________________________________

Privacy Notice

Personal information will be managed openly and transparently in a way that protects an individual’s privacy and respects their rights under Australian privacy laws.

We only collect or use personal information if this is needed to education and care to children at the service, or to comply with our legal obligations. We will take reasonable steps to make sure you know we have your personal information, how we got it and how we’ll handle it.

We collect most personal information directly from a parent or guardian. We may also collect information through our website, social media page , Family Law court orders or agreements, special needs agencies and training courses. We may occasionally request information from other organisations which you would reasonably agree is necessary for us to educate and care for a child.

The information collected includes information required under the National Education and Care Law and Regulations or needed to promote learning under the Early Years Learning Framework. This includes name, address, date of birth, gender, family contact details, emergency contact details, authorised nominee details, parents’ occupations, cultural background, home language, religious beliefs, payment details, child care subsidy information, Medicare number, , immunisation records, medical information and medical management plans, photos of children and information about children’s strengths, interests, preferences and needs, including special needs.

We do not disclose personal information to others unless you would reasonably expect us to do this, we have your consent or we are complying with an Australian law.

We aim to keep the personal information we hold accurate, up-to-date and complete. This enables us to provide high quality education and care while ensuring the health and safety of children, and it is also important that we can contact you in the event of an emergency.

We have systems and practices in place to ensure personal information is secure and can only be accessed by those who need the information or may legally access it.

You have the right to access your personal information. There are some circumstances under Australian privacy laws where we may not be able to give you access. We will tell you if this is the case. There is generally no cost for accessing your information. We will tell you if there is a charge before providing access.

Our Privacy Officer for privacy matters, including complaints, is the Approved Provider or Nominated Supervisor who may be contacted by telephone on INSERT PHONE NUMBER or email INSERT EMAIL ADDRESS or by mail INSERT POSTAL ADDRESS.

We will provide a copy of any updates to our Privacy and Confidentiality Policy on our Service Noticeboard and include the changes in our Newsletter.