SURFCOAST VACATION CARE PROGRAM ENROLMENT FORM SEPTEMBER 2011 Parent/Guardian Surname: Parent/Guardian CRN: _______________________________

PLEASE NOTE: If you are a new family to the service a customer reference number (CRN) for the family and children are now required before any bookings can be processed. To obtain CRNs contact the Family Assistance Office on 136150. Parent Full Name & Date of Birth: __________________________________________ D.O.B.___________________________________________ Other Parents Name & Date of Birth: Is Any Other Surname Used?: Y or N ________________________________________ D.O.B. _______________________________ If yes please provide surname: __________________________________________________________

Home/Billing Address: (Is this where child/children reside?) Y/N __________________________________ ______________________________________________________________________________________ ______________________________________________________________________ If Child Resides Elsewhere Address Details: Telephone:(H) _______________________________________________________________________________ ____ (M) ___

_________ (W)

Name & address of another person to contact in case of emergency, if you are unable to be contacted: Name: __________________________ ____Address:________________________________________________________________ Telephone: (H) CHILD/CHILDRENS REGULAR SCHOOL: CHILD/CHILDREN ATTENDING THE PROGRAM: 1. 2. 3. 4. Name: Name: Name: Name: ____________________________DOB: __________ CRN: ___________________________ DOB__________ CRN: ___________________________ DOB: _________ CRN: ___________________________ DOB__________ CRN: Has your child been immunised?YES/NO Has your child been immunised? YES/NO Has your child been immunised? YES/NO Has your child been immunised? YES/NO _____ (W) (M)_____________________________________________

____________________________________________________________________________

Are your children from a non English speaking background? YES NO Are they Aboriginal/Torres Strait/South Sea Islanders? YES/NO Do your children have any special food, religious or other requirements YES/NO If yes please list in the space provided.

Please list any medical condition or allergies for each child enrolled in the vacation care program and advise staff on the childs first day. A medication authorisation form must be completed if your child requires any medication whilst at the program. If your child is diagnosed as at risk of Anaphylaxis you must provide a Anaphylaxis Action Plan signed by your doctor and an up to date Epipen. Your child will not be allowed to attend if the plan and Epipen are not brought to the program each day your child attends. Name: ____________________ Medical Condition: Doctor: Doctor: Doctor: Doctor: PH: ____________ ____ PH: _________________ PH: ________________ PH: ________________

Name: ____________________ Medical Condition: Name: Name: ____________________ Medical Condition: ____________________ Medical Condition:

PLEASE ANSWER THE FOLLOWING QUESTIONS 1. Are you using the program for work related reasons? Y/N 2. Will you be collecting your children each day? Y / N * If no please provide details of authorised person over page. 3. Will you be claiming Child Care Benefit? Y/N 4. Have you registered this service with Centrelink? Y/N 5. Has Centrelink advised you of your CCB entitlement? Y/N 6. Have you received a copy of your assessment notice? 7. Will you be claiming CCB at another service during the program? Y / N * If yes please provide name of service 8. Do you realise we have a 7 day cancellation policy. Tell parent Y 9. Please ensure your child brings along their own named water bottle. Tell parent Y 10. Please ensure your child brings enough food and drink to last all day. Tell parent Y 11. Please ensure no food with nut products are brought into the program due to some children being at risk of anaphylaxis. Tell parent - Y 12. All children must bring a broad brimmed hat. Tell parent Y 13. Spending money for excursion days is capped at $10.00. For 5-8 year olds it must be put into a named snap lock bag & given to the Coordinator for safe keeping. In line with our healthy food policy spending money is for souvenirs & healthy food only. - Y 14. Are there any special access/custody arrangements? Y / N If yes please advise the service in writing. 15. Does a court order or other relevant restriction apply? Y / N If yes please provide the service with relevant legal paperwork and details. 16. All forms MUST be signed prior to your child/children entering our program. Forms can not be signed on the first day. PLEASE COMPLETE ENROLMENT RECORD ADDENDUM ON THE NEXT PAGE.

shpenrolform

FURTHER INFORMATION ABOUT YOUR CHILDREN TO SHARE WITH OUR PROGRAM STAFF

Childs names Are there any activities that your child particularly enjoys or has a special interest in? _______________________________________________________________________________________________________ Are there any other special considerations the staff will need to be aware of to ensure the participation of your child in all activities?

What are the identified goals for your childs inclusion into the school holiday program? _______________________________________________________________________________________________________ What is a calming activity for your child? _______________________________________________________________________________________________________ What is your childs favourite activity to do at school? ______________________________________________________________________________________________________ Any further comments?
_________________________________________________________________________________________________________________________________ _

PRIVACY POLICY The Surfcoast Shire considers that the responsible handling of personal information is a key aspect of democratic governance, and is strongly committed to protecting an individuals right to privacy. Council will comply with the information privacy principles as set out in the Information Privacy Act 2000. Surfcoast Sport & Recreation Centre will only use the personal information on this form for the purpose of statistics and child care benefit requirements. The information will not be disclosed to any other party unless Council is required to do so by law. You can view and change the information by contacting the office on 52614606. DECLARATION I the undersigned approve of the enrolment and agree to abide by the policies and procedures of the program and meet any costs as advertised. I authorise the Coordinator in the event of any unforeseen accident or illness to obtain medical assistance or an ambulance as required and agree to meet any expenses attached to such treatment. I give permission for my child/ren to be taken on any excursions and outings as organised by the program and to watch G or PG rated movies/dvds. I will accept full responsibility for my childs belongings and any spending money whilst attending the program. I fully understand that if my child continuously misbehaves, and after behaviour guidance procedures have been followed, I will be notified and my child may be removed from the program. I agree to give the program 7 days notice for any absence of my child/ren and accept that the full fees will be charged if less than 7 days notice is given. I acknowledge that my child/ren will not attend the program if suffering from an infectious or contagious illness. In the event that my child is injured or becomes ill during the program, either an authorised person or myself shall collect the child as soon as practical. I authorise leaders to apply sunscreen to my child and to wear a hat provided by the program for use outdoors if necessary. I give consent to the staff to take photographs or video footage of my child during activities in the program for the Commonwealth Government Quality Assurance Accreditation and for other promotional use of the program. Signed:_____________________________________ Parent/Guardian Dated: ______________________________________ AUTHORISATION TO COLLECT CHILDREN: Name of persons: ____________________________ ____________________________________________________________________________ ___________________________________________ ____________________________________________________________________________ Relationships: __________________________ ____ Dates: ______________________________________________________________________ Office Use Only: Date / / Amount Paid $ Date / / Amount Paid $

PLEASE ENSURE THAT ALL REQUIRED AREAS ARE SIGNED ON THIS ENROLMENT FORM BEFORE IT IS RETURNED TO OUR OFFICE. PLEASE NOTE WE NO LONGER ACCEPT PHONE BOOKINGS.
shpenrolform

SURFCOAST VACATION CARE PROGRAM BOOKINGS

DATES NAMES OF CHILDREN ATTENDING WEEK 1 MON 26th REGULAR PROGRAM (please tick) BIG DAY OUT PROGRAM (please tick)

TUES 27th

WED 28th

THURS 29th

FRI 30th

SURFCOAST VACATION CARE PROGRAM BOOKINGS

DATES NAMES OF CHILDREN ATTENDING WEEK 2 MON 3rd REGULAR PROGRAM (please tick) BIG DAY OUT PROGRAM (please tick)

TUES 4th

WED 5th

THUR 6th

FRI 7th

NO NUTS THIS FACILITY IS TOTALLY NUT FREE. NO NUTS OR NUT PRODUCTS DUE TO A NUMBER OF CHILDREN AT RISK OF ANAPHYLAXIS

shpenrolform

Enrolment record addendum for childrens services Childrens Names & Dates of birth - Name.. Name. Name. Name. Date of Birth Date of Birth Date of Birth Date of Birth

A parent or guardian who has lawful authority in relation to the child must complete this form. A brief explanation of lawful authority is found at the end of this form. Licensed childrens services may use this form to collect the childs enrolment information as required in regulations 31 to 35. Health Information Does child/children have any special needs? Yes No

If yes, please provide name & details of any special needs and any management procedure to be followed with respect to the special need. .. Anaphylaxis Has your child been diagnosed at risk of anaphylaxis? Yes Name of child___________________________________________________________ (only if you answered yes to above question) Does your child have an auto injection device (eg EpiPen)? Has the anaphylaxis medical management plan been provided to the service? Has a risk management plan been completed by the service in consultation with you? Yes No

No

Yes Yes

No No

In the case of anaphylaxis you will be provided with a copy of the services anaphylaxis management policy. You will be required to provide the service with an individual medical management plan for your child signed by the medical practitioner who is treating your child. This will be attached to your childs enrolment form. More information can be found at www.education.vic.gov.au/anaphylaxis Does your child/children have a child health record? If yes, please provide to the service for sighting Yes No Yes No

Child health records means a record that documents a childs health and development assessments and immunizations. Name and position of person at the childrens service who has sighted the childs health record. Name________________________________________________Position______________________________________________ Confidentiality of enrolment records The proprietor of the childrens service must ensure that information in the childs enrolment record is not divulged to another person unless necessary for the care or education of the child, to manage medical treatment of the child, where expressly authorized by the parent or prescribed in the Childrens Services Regulations 2009 (regulation 35(1)(d-e) I, ____________________________________________________(name) declare as the person with lawful authority of the child referred to in this enrolment form that the information provided is true and correct and undertake to immediately inform the childrens service in the event of any change to this information. Parents signature________________________________________________Date____________________________
Lawful Authority Parents All parents have powers and responsibilities in relation to their children that can only be changed by a court order. The Childrens Services Regulations 2009 refer to these powers and responsibilities as lawful authority. It is not affected by the relationship between the parents, such as whether or not they have lived together or are married. A court order, such as under the Family Law Act, may take away the authority of a parent to do something, or may give it to another person.

shpenrolform

Guardians A guardian of a child also has lawful authority. A legal guardian is given lawful authority by a court order. The definition of guardian under the Childrens Services Act 1966 also covers situations where a child does not live with his or her parents and there are no court orders. In these cases, the guardian is the person the child lives with who has day-to-day care and control of the child.

shpenrolform