Confidential Enrolment Form

"*" indicates required fields

1Education & Care Service Details

2Child Information

3Siblings and Co-Residents

4Parent and Guardian Information

5Other Authorised People

6Court Orders In Relation To The Child

7Child's Immunisation Status

8Child's Health Information

9Child's Medical Information

10Additional Information

11Authorisation and Declaration

Education & Care Service Details

Date*

DD slash MM slash YYYY

Year of Attendance*

Name of Service*

Child's Group*

3yo kinder

4yo kinder

Other

if other is selected

Child Information

Name*

Given Name Family Name

Preferred Name (if applicable)

Date of Birth*

DD slash MM slash YYYY

Gender*

Male

Female

Other

Child CRN (long day care only)

CRN (Customer Reference Number) is required ONLY for Long Day Care Enrolments. Visit familyassistance.gov.au or call 136 150

Country of Birth*

Country

Home Address*

Street Address City State Post Code Country

Religion

Is the child of Aboriginal &/or Torres Strait Islander origin?*

Language used in child's home*

Cultural background of the child & if applicable, the child’s parents*

Does this child live with:*

Details of who this child lives with:

Does this child or their family currently have a humanitarian or refugee visa?*

If Yes, please select visa type:

Which type of visa?

Siblings and Co-Residents

Age & Gender of Child’s Brothers & Sisters (if applicable)

Childs Name

Date of Birth

DD slash MM slash YYYY

Gender

Age & Gender of Child’s Brothers & Sisters (if applicable)

Any other person/s living in the child’s home (e.g.: grandparents) (if applicable)

Persons Name

Known to the child as

Relationship to the child.

Any other person/s living in the child’s home (e.g.: grandparents) (if applicable)

Parent and Guardian Information

Is there one or two parents/guardians with parental/guardian rights for your child?

One

Two

Please fill in parent/guardian one details only

Please fill in the details for parent/guardian one and two.

Parent or Guardian 1*

Parent or Guardian 1 - Name*

Prefix First Last

Parent or Guardian 1 - DOB

DD slash MM slash YYYY

Country of Birth of Parent/Guardian*

Parent or Guardian 1 - Address*

Street Address City State Post Code Country

Parent or Guardian 1 - Phone (Mobile Preferred)*

Parent or Guardian 1 - Phone - Work

Parent or Guardian 1 - Email*

Parent or Guardian 1 - Occupation

Parent or Guardian 1 - Does the child live with this parent/guardian?*

Parent or Guardian 1 - Parent/guardian CRN (long day care only)

Visit familyassistance.gov.au or call 136 150

Parent or Guardian 1 - What is the highest year level of school parent/guardian has completed? (Select one) (For persons who have never attended school, mark ‘Year 9 or equivalent or below’.)*

Parent or Guardian 1 - What is the level of the highest qualification parent/guardian has completed? (select one)*

Parent or Guardian 1 - What is the occupation group of parent/guardian?*

Please select parental occupation group from the list: Click Here
if you have not been in paid employment for the last twelve months because you have been at home caring for your own children please select H.

Parent or Guardian 2

Parent or Guardian 2 - Name

Prefix First Last

Parent or Guardian 2 - DOB

DD slash MM slash YYYY

Country of Birth of Parent/Guardian

Parent or Guardian 2 - Address

Street Address City State Post Code Country

Parent or Guardian 2 - Phone (Mobile Preferred)

Parent or Guardian 2 - Phone - Work

Parent or Guardian 2 - Email

Parent or Guardian 2 - Occupation

Parent or Guardian 2 - Does the child live with this parent/guardian?

Parent or Guardian 2 - Parent/guardian CRN (long day care only)

Visit familyassistance.gov.au or call 136 150

Parent or Guardian 2 - What is the highest year level of school parent/guardian has completed? (Select one) (For persons who have never attended school, mark ‘Year 9 or equivalent or below’.)

Compulsory, please complete

Parent or Guardian 2 - What is the level of the highest qualification parent/guardian has completed? (select one)

Compulsory, please complete

Parent or Guardian 2 - What is the occupation group of parent/guardian?

Compulsory, please complete
Please select parental occupation group from the list: Click Here
if you have not been in paid employment for the last twelve months because you have been at home caring for your own children please select H.

Other Authorised People

Please list below the details of those people who you have authorised as emergency contacts for your child. This list may be amended at any time. In the event that the parents or guardians cannot be contacted, the person/s listed below with authority will be contacted regarding collecting your child, in the event of an emergency involving your child, consent treatment or the administration of medication, or to authorise an Educator to take your child outside of the Service premises. Please tick the appropriate boxes for each contact to confirm authorisations.

Person 1 - Name*

Prefix First Last

Person 1 - Address*

Street Address City State Post Code Country

Person 1 - Phone (Mobile Preferred)*

Person 1 - Phone - Work

Person 1 - Relationship to child

Person 1 - Authorised to collect (Authorised Nominee) (Reg.160(3)(b)(iii))*

Person 1 - Other Authorisations

Please select which things you are authorising the person to do

Notification in the event of an emergency (Reg.160(3)(b)(ii))

Authorised to consent to medical treatment (Reg. 160(3)(b) (iv))

Authorisation for the administration of medication (Reg.160(3)(b)(iv))

Authorised to authorise an Educator to take the child outside of the premises (Reg.160(3)(b)(iv)&(v))

Person 2 - Name

Prefix First Last

Person 2 - Address

Street Address City State Post Code Country

Person 2 - Phone (Mobile Preferred)

Person 2 - Phone - Work

Person 2 - Relationship to child

Person 2 - Authorised to collect (Authorised Nominee) (Reg.160(3)(b)(iii))

Person 2 - Other Authorisations

Please select which things you are authorising the person to do

Notification in the event of an emergency (Reg.160(3)(b)(ii))

Authorised to consent to medical treatment (Reg. 160(3)(b) (iv))

Authorisation for the administration of medication (Reg.160(3)(b)(iv))

Authorised to authorise an Educator to take the child outside of the premises (Reg.160(3)(b)(iv)&(v))

Court Orders In Relation To The Child

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

Court orders*

No, Please go to next section

Yes, Please complete the following

Prior to commencement at the service, please bring the original order/s for Educators to sight and attach a copy to this enrolment form;

Please describe the orders and provide the contact details of any person given powers, duties, responsibilities or authorities;*

Child's Immunisation Status

Please provide the immunisation status for this child (select one of the following)

Before commencing please bring a copy of your Child History Statement from the Australian Childhood Immunisation register OR ‘other’ acceptable documentation as outlined in the Early Education and Care services Immunisation Toolkit- please speak to the Teacher about other acceptable documentation.

Child's Health Information

Registered Medical Practitioner/ Medical Service Name*

Practitioner/ Service Phone*

Practitioner/ Service Address*

Street Address City State Post Code

Permission to contact Maternal child health

Maternal & Child Health (MCH) Centre

Maternal & Child Health (MCH) Centre Contact

Has your child had the 2 year old MCH check?

Yes

Has your child had the 3 ½ year old MCH check?

Yes

Medicare No.*

Medicare Expiry Date*

DD slash MM slash YYYY

Ambulance Subscription No. (if applicable)

Does the family have a Commonwealth Health Care Card?*

Yes

Commonwealth Healthcare Card Expiry Date*

DD slash MM slash YYYY

*Does the family have a Pensioner Concession Card?*

Yes

Pension Concession Card Expiry Date*

DD slash MM slash YYYY

Does Family have a Department of Veteran's Affairs Gold or White Card*

Yes

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

Yes

Does your child need a high level of assistance with core activities because of disability or health condition?*

Yes

If yes, please provide details of the assistance required

Is the child receiving funding through NDIS?

Yes

If yes, please provide details

Is the child currently attending or has previously attended

Councillor/Psychologist

Occupational therapy

Paediatrician

Specialist

Speech Therapy

Dietitian

Other

Child's Medical Information

Learn more about Medical Management Plans Epilepsy Asthma Diabetes

ANAPHYLAXIS (Reg. 162(c)(iii)&(d))

Has your child been diagnosed as at risk of anaphylaxis?*

Does your child have an auto injection device (e.g.EpiPen® or Anapen®)?*

If your child has an auto injection device, you have to supply a device with a valid expiry date, to the service, prior to commencement. In the case of anaphylaxis, you will be required to provide the service with an individual medical management plan for you child signed by the medical practitioner who is treating your child prior to commencement at the service. You will be required to complete a risk minimisation and communication plan in consultation with the Educator prior to commencement. You will also be provided with a copy of the service’s anaphylaxis management policy. This will be attached to your child’s enrolment form. More information can be found at allergyfact.org.au

SPECIFIC HEALTHCARE NEEDS (Reg.162(c)(i)&(d))

Does your child have any specific healthcare needs including any medical conditions that are relevant to the care and education of your child? (e.g. asthma, epilepsy, diabetes etc.)*

If YES, you will be required to provide the service with an individual medical management plan for you child signed by the medical practitioner who is treating your child prior to commencement at the service. You will be required to complete a risk minimisation and communication plan in consultation with the Educator prior to commencement.

If necessary, will you be providing medication to the service*

ALLERGIES (Reg.162(c) (iii))

Does your child have any allergies?*

If Yes, prior to you child’s commencement at the service, please provide details of any allergy and any management plan/s or risk minimisation plan/s to be followed with respect to the allergy.

If necessary, will you be providing medication to the service*

DIETARY RESTRICTIONS (Reg.162 (e))

Does your child have any dietary restrictions?*

If Yes, please provide any details of any dietary restrictions

Additional Information

Is your child attending or previously attended

Kindergarten

Playgroup

Long Day Care

Family Day Care

Early Intervention Service

Other

If yes, please provide details

If applicable, which school have you or do you plan to enrol your child?

Do you allow sunscreen to be applied to your child while in the care of the Education and Care Service?*

Do you give permission to conduct head lice checks?*

Please indicate festivals/celebrations your family recognises and/or list below any cultural/religious beliefs you wish the Educators to be aware of

Birthdays

Christmas

Diwali

Easter

Mother’s Day

Father’s Day

Hanukkah

NAIDOC week

Ramadan

Please list other specific information related to the above

Do you have any specific skills or a trade that could be of use to the Education and Care Service?

Authorised Nominee/s means a person who has been granted permission by a family member* to collect the child from the Education and Care Service (Education and Care Services National Law 170(5)). Family Member/s as defined in the Education & Care Services National Law 2010; section 5 ‘family member’ in relation to a child, means- (a) a parent, grandparent, brother, sister, uncle, aunt or cousin of the child, whether of the whole blood or half-blood and whether that relationship arises by marriage (including de facto relationship) or by adoption or otherwise; or (b) a relative of the child according to Aboriginal or Torres Strait Islander tradition; or (c) a person with whom the child resides in a family like relationship; or (d) a person who is recognises in the child’s community as having a familial role in respect to the child. Parental Responsibility is defined in the Family Law Act 1975 as “all duties, powers, responsibilities and authority which, by law, parents have in relation to children” All parents have powers and responsibilities in relation to their children, which can only be changed by a court order. These powers and responsibilities are referred to as “parental responsibility”. 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.

The Approved Provider of the Education and Care Service (ECKA) must ensure that the information in your child’s enrolment record is not divulged or communicated, directly or indirectly, to another person other than as prescribed under Regulations 181 and 182 of the Education and Care Services National Regulations 2011. This includes, to the extent necessary for the education and care of your child or medical treatment of your child; or where expressly authorised, permitted or required to be given by or under any Act or law; or with the written consent of the person who provided the information.

Authorisation and Declaration

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I (Full Name),

a person with parental responsibility of the child referred to in their enrolment form (Reg161) authorise the Approved Provider (ECKA), Nominated Supervisor, or an educator to seek;*

medical treatment for the child from a registered medical practitioner, hospital or ambulance service; and

transportation, an authorise of the child by an ambulance; and

if relevant, an authorisation given under Regulation 102 of the Education and Care Service to take the child on regular outings

Consent*

I agree that I am responsible for any expenses incurred during a medical emergency in relation to the child;

I agree to collect or make arrangements for the collection of the child if he or she becomes unwell;

I understand that in an emergency situation or where evacuation is necessary that the child may need to leave the Education and Care service under the direction and supervision of the approved provider, nominated supervisor or educator;

I have read & understood that I must comply with ECKA’s policies including the ‘Payment of Fees’

I declare that the information in the enrolment form is true and correct and undertake to immediately inform the Education and Care Service in the event of any change to this information;

I declare that my child will be accessing their funded kindergarten place at this service. (kindergarten funding can only be claimed at one service per year. If you are enrolled in another early childhood centre, you must inform them that the funding for kindergarten will accessed through this enrolment).

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Signature of person with parental responsibility of the child

This field is hidden when viewing the form

Date

Education & Care Service Details

Child Information

Siblings and Co-Residents

Parent and Guardian Information

Other Authorised People

Court Orders In Relation To The Child

Child's Immunisation Status

Child's Health Information

Child's Medical Information

ANAPHYLAXIS (Reg. 162(c)(iii)&(d))

SPECIFIC HEALTHCARE NEEDS (Reg.162(c)(i)&(d))

ALLERGIES (Reg.162(c) (iii))

DIETARY RESTRICTIONS (Reg.162 (e))

Additional Information

Authorisation and Declaration

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