ENROLMENT FORM QLD

 

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)

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

PARENT DETAILS

 

Parent One Parent Two
Where answer is same as Parent One write same
Surname ________________________________ ________________________________
Given Names ________________________________ ________________________________
Preferred name ________________________________ ________________________________
Date of birth ________________________________ ________________________________
Occupation ________________________________ ________________________________
Home address ________________________________ ________________________________
________________________________ ________________________________
Home phone ________________________________ ________________________________
Work phone ________________________________ ________________________________
Mobile ________________________________ ________________________________
Best contact number ________________________________ ________________________________
Email ________________________________ ________________________________
________________________________ ________________________________
Parent’s CRN ________________________________ ________________________________
Country of birth ________________________________ ________________________________
Preferred language ________________________________ ________________________________
Does the child live with you? ________________________________ ________________________________
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 attach one or more of the following documents:

A current Australian Childhood Immunisation Record (ACIR) Statement

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

ACIR Immunisation History and Exemption forms are available on the Department of Human Services website  http://www.humanservices.gov.au/ The ACIR can be  contacted on 1800 653 809 or email acir@medicareaustralia.gov.au

I have read the Immunisation and Disease Prevention Policy which is attached and agree to comply with the immunisation requirements outlined in the policy. I understand my child’s enrolment or attendance at the service may be terminated if I do not comply with the requirements in the policy

Parent 1 Signature_____________________________________
Parent 2 Signature_____________________________________
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

If yes, please provide details

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

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 and/or to administer life saving medication (eg Epipen or Ventolin) in a medical 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

  • agree to the administration of life saving medication like Epipen in event of anaphylaxis or Ventolin during an asthma attack
  • 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      ___________________________

 

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.