ENROLMENT FORM 2012

 

Child’s Full Name
Also Known as (Nickname or abbreviated name)			Sex
Any Former Names
Date of Birth		Place of Birth
Primary Residential Address
Is your child Aboriginal or Torres Strait Islander?       Yes / No
Ethnic/ Cultural Background
Is English the second language spoken in the home?  Yes / No
What is the primary language spoken in the child’s primary residence?
Are there any cultural or religious practices you wish your child to observe while at preschool?
Are there any celebrations you wish your child to obstain from whilst at the preschool?
Are there any other children in your family?  Yes / No If yes, please list their names and ages
Please inform us of your family circumstances ie: Defence family, parents separated, blended family or custodial arrangements.
Is your child subject to any court orders, parenting orders or parenting plans?      Yes / No If yes, we must sight the original court order or duly certified copy to be able to enforce it.
Has your child attended an early childhood service prior to enrolment at the preschool?  Yes  / No
Which primary school will you enrol your child to attend?

Parents/Guardians:

Full Name	Full Name
(Any other names By which known)	(Any other names By which known)
Home Address	Home Address
Home Phone Number	Home Phone Number
Date of Birth	Date of Birth
Place of Employment	Place of Employment
Work Phone Number	Work Phone Number
Mobile	Mobile
Email	Email
Skills I can volunteer (e.g sewing, electrician, plumber)	Skills I can volunteer (e.g sewing, electrician, plumber)

Do you wish to receive the following electronically? Please circle

Newsletters                               Yes/No

Fee invoices                              Yes/No

Excursion notices                      Yes/No

You may be entitled to reduced fees if you hold one of the following:

p                  Low income Health Care Card

p                  Pensioner Concession Card

p                  Department of Veterans Affairs Gold Card

p                  Visa S.447 5451 5785 5786                                                        Sighted: …………………………………

Health information

Doctor’s name
Medical practice name
Address
Phone number
Child’s Medicare number
Is the child covered by Private Health insurance?  Yes / No If yes, please specify the name of the health fund
Is your child’s immunised?  Yes / No If yes, please provide your child’s immunisation record to the preschool.
Does your child have any specific healthcare needs, such as any medical condtions, allergies or intolerances?  Yes / No
Does your child have any specific dietary requirements?  Yes / No  If yes, please specify.
Does your child have any known allergies or intolerances?  Yes / No If yes, you will need to complete the Allergy and Intolerances Record Form (H2)
Has your child been diagnosed as at risk of anaphylaxis or has anaphylaxis?  Yes / No If yes, you will need to complete the Anaphylaxis Management Plan (H5)
Does your chld suffer from asthma?  Yes / No If yes, you will need to complete the Asthma Record Form (H1)
Does your child have any other medical conditions? Yes / No If yes, please complete the Medical Plan (H3)
Has your child been seen by a specialist? (e.g. speech therapist, occupational therapist? Yes / No If yes, please give details and copy of relevant reports

In case of emergency: Please provide details of an alternative contact person in the Bungendore area, who we can contact if we can’t contact either parent in an emergency.  By providing this persons details you are authorising them to be able to collect your child from the preschool and authorise medication, medical treatment or first aid treatment for your child.

Full Name			Relationship to the child
Address
Home Phone		Work Phone	Mobile

Full Name			Relationship to the child
Address
Home Phone		Work Phone	Mobile

Persons authorised to collect my child/ren (besides parents/guardians named previously) are:

Full Name			Relationship to the child
Address
Home Phone		Work Phone	Mobile

Full Name			Relationship to the child
Address
Home Phone		Work Phone	Mobile

Full Name			Relationship to the child
Address
Home Phone		Work Phone	Mobile

Children will not be allowed to leave the preschool with anyone who is not authorised to collect them.

Authorisations

Medical Authorisation

I hereby authorise the staff of Bungendore Preschool to seek emergency medical, hospital, dental treatment or ambulance service for my child, if the staff feel it necessary to do so because my child is injured or ill.  I understand that I will incur the costs of ambulance transportation.

Signed: …………………………….  Parent / Guardian        Date: …/…/…

or contact my Dr of Choice: …………………………….

Asthma First Aid

I hereby authorise the staff at Bungendore Preschool to administer Asthma First Aid if my child has difficulty breathing, or has a first attack of asthma at preschool.

Signed: …………………………….  Parent / Guardian        Date: …/…/…

Excursion Authorisation

I hereby authorise for my child to participate in routine excursions from the Bungendore Preschool to places in our local community.  These excursions may include, but are not limited to, excursions to Bungendore Community Library, walks around local area, going to the local park.   In the event of inclement weather for such excursions, I understand that my child may be transported by bus with Stevens Charter Service.  This authority is valid for 2012.

Signed: …………………………….  Parent / Guardian        Date: …/…/…

Permission to Use Photos

I authorise the staff at Bungendore Preschool to photograph my child                                             Yes / No

I authorise for my child’s photo to be used in any media publication to promote the preschool      Yes / No

I authorise for my child’s photo to be used in documentation and displayed within the preschool  Yes / No

I authorise for child’s photo to be included in their friends’ portfolios                                              Yes / No

Signed: …………………………….  Parent / Guardian        Date: …/…/…

Fee Policy Acknowledgement

I understand that if fees are overdue by two (2) weeks from the previous instalment date and no contact has been made with the preschool to vary the fee instalments, I may be asked to remove my child/ren from the preschool. I also understand that my child/rens place within the preschool will be allocated to the next child on the waiting list if my fees are not paid.

Signed: …………………………….  Parent / Guardian        Date: …/…/…

Administration Policy – Confidentiality

The information that you give the preschool will be used for our purposes and will not be disclosed to any other person or organisation, unless there is a legal requirement to do so. However, in the event of medical assistance for your child, it may be necessary to provide some personal information to the person providing the service. In the unlikely event that the preschool wants or needs to provide personal information to any other person, we will first seek your consent.

I have read the “Enrolment Information 2012” and agree to abide by the conditions therein.

Signed: …………………………….  Parent / Guardian        Date: …/…/…

__________________________________________________________________________________

For office use only

Paid deposit:		Receipted:
Date commenced:		Records entered:

Attached

o    Copy of Birth certificate/Passport                                 o             Allergy and Intolerance Record

o             Copy of Immunisation Certificate                                 o             Asthma Plan

o             Copy of Court Order                                                   o             Medical Management Plan

o             Fee Relief Application                                                 o             Anaphylaxis Management Plan

Fee Relief Approval

Term 1 – Sighted

Term 2 – Sighted

Term 3 – Sighted

Term 4 Sighted

Child’s Name: ……………………………………………………………………..           Date of Birth …/…/…

Child’s Development Any concerns about language, co-ordination, behaviour?

Child’s Likes and Dislikes (e.g. dislikes loud noises, likes messy craft)

Any other information to help us care for your child (e.g. previous childcare, separation anxiety)

Reason for Sending your Child to Preschool. What do you hope your child will gain from preschool?