Crèche enrolment form

Keilor Basketball Netball Stadium

 

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. The licensed children’s services must collect the child’s enrolment information in this form, as required by the Children’s Services Regulations 2020 (Regulations). Questions marked with an asterisk * are not required by the Children’s Services Regulations 2020, but you are encouraged to answer these to assist in providing relevant children services.

 

 

 

Information about the child

Family name:

     

Date of birth:

[ ] Male [ ] Female

Given name:

     

Usually called:

Address:

     

Suburb:

     

Postcode:

     

 

Cultural Background:

     

Language Spoken at home:

     ____________________________________________________________________

Parent’s Email:

     

 

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

[ ]

No not aboriginal or Torres Strait Islander

[ ] Yes Aboriginal

[ ] Yes Aboriginal and Torres Strait Islander

[ ] Yes Torres Strait Islander

 

 

Information about the child’s parents or guardians

Parent 1

 

Parent 2

Name:

  

Name:

Address – as per child or:

 

Address – as per child or:

  

Telephone numbers:

 

Telephone numbers:

(h)      

(w)      

(m)      

 

(h)      

(w)      

(m)      

Does the child live with you [ ] Yes [ ] No

 

Does the child live with you [ ] Yes [ ] No

 

 

 

Guardian 1 (if applicable)

 

 

Guardian 2 (if applicable)

Name:

  

Name:

Address - as child or:

 

Address – as per child or:

  

Telephone numbers:

 

Telephone numbers:

(h)      

(w)      

(m)      

 

(h)      

(w)      

(m)      

Does the child live with the guardian [ ] Yes [ ] No

 

Does the child live with the guardian [ ] Yes [ ] No

 

 

 

 

 

Other persons to be notified

There may be times when the child has an accident, injury, trauma or illness and the parents or guardians cannot be contacted. To deal with these situations the children’s service should notify one of the following people who are authorised to collect and care for the child after accident, injury trauma or illness.

Name:

  

Name:

Address

  

Address

     

Telephone numbers:

 

Telephone numbers:

(h)      

(w)      

(m)      

 

(h)      

(w)      

(m)      

 

 

 

Authorised Nominees to collect your child - Consent
Your consent is required for other people (Authorised Nominees) to collect the child from the children’s service on your behalf. Please list the details of those people who can collect the child in the table below.

In the event that the child is not collected from the children’s service and the parents or guardians cannot be contacted, this list will also be used to arrange someone to collect the child

Details of people who can collect the child (Authorised Nominees). This list may be added to or changed throughout the year.

Name:

  

Name:

Address:

  

Address:

     

Telephone numbers:

 

Telephone numbers:

(h)      

(w)      

(m)      

 

(h)      

(w)      

(m)      

   

 

Name:

  

Name:

Address:

 

Address:

  

Telephone numbers:

 

Telephone numbers:

(h)      

(w)      

(m)      

 

(h)      

(w)      

(m)      

   

 

 

 

 

 

 

Confidential: Court orders relating to the child

Are there any court or tribunal orders, parenting orders or parenting plans relating to 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 the child's contact with a parent or other person?  

[ ] No go to the next section.

[ ] if Yes, please complete the following:

1.  Bring the original court order/s for staff to see and a copy to attach to this enrolment form

2.  If these orders:

a.  Change the powers of a parent/guardian to:

•  Authorise the taking of the child outside the service by a staff member of the service

•  Consent to the medical treatment of the child

•  Request or permit the administration of medication to the child

•  Collect the child, AND/OR

b.  Give these powers to someone else,

Please describe these changes and provide the contact details of any person given these powers:

     

 

 

Child’s medical and health information

Doctor/medical service details

Name:

     

Telephone:

 

Address:

     

Suburb:

     

Postcode:

     

Maternal & Child Health Centre:

     

 

Has the child had their 3 ½ year old assessment?   [ ] Yes [ ] No

If yes provide details by attaching a copy of the 3 ½ year assessment from the Child Health Record Book.

Does the child have any allergy or sensitivity?   [ ] Yes [ ] No

If yes, the following management procedures are to be followed (or a copy of the management plan is attached):

     

 

Does the child have any medical conditions and needs (eg epilepsy, asthma, diabetes, etc) which are relevant to the children’s service?

If yes, the following management procedures are to be followed (or a copy of the management plan is attached):

     

 

Does the child have any dietary restrictions?   [ ] Yes [ ] No

If yes, the following restrictions apply:

     

 

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

 

 

*If yes, does your child receive support from an agency or network? [ ] Yes [ ] No Agency ___________________

 

Child’s immunisation record

Has the child been immunised?   [ ] Yes [ ] No

If yes, provide the details by attaching the child’s immunisation history statement from the Australian Immunisation Register via MyGov Medicare.

Confidential: Other information

If there is anything else that the children’s service should know about the child (eg excessive fears, favourite activities, attending other early childhood service or intervention service, etc) describe below:

     

 

 

 

 

Declaration and consent to emergency medical treatment

I,

 

(Print full name)

 

a person with lawful authority of the child referred to in this enrolment form,

•  Declare that the information in this enrolment form is true and correct and undertake to immediately inform the children’s service in the event of any change to this information

•  Agree to collect or make arrangements for the collection of the child referred to in this enrolment form if the child becomes unwell at the service

•  Consent to the staff of the children’s service seeking, or where appropriate, administering, such emergency medical treatment as is reasonably necessary and that I will reimburse any necessary expenses incurred by the children’s service.

I declare and consent to the above [ ] Yes [ ] No

Photograph

Throughout the year crèche staff will be doing activities and special events with the children that may require your child being photographed.

Any photos taken will be used solely for the use of crèche staff and/or crèche activities. We require your permission for your child to be photographed.

I give my permission for staff to take photos of my child/children for use in crèche activities or special events.

[ ] Yes [ ] No

Acknowledgement

I acknowledge that I must always remain within the facility while my child is attending crèche.

[ ] Yes

Parent/Guardian Name:

Signed:

 

Date:

 

 

Lawful Authority

Parents

All parents have powers and responsibilities in relation to their children which can only be changed by a court order. The Children’s Services Regulations 2020 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.

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 Children’s Services Act 1996 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.

Council Privacy Statement

The personal information requested on this form is being collected by Council for reference and identification purposes. To ensure confidentiality of information requested, we will only use personal information provided by you for the purposes of offering a range of leisure services and programs. The information may also be disclosed to third party providers acting on behalf or as agents of Council or in instances where Council is required by law to release or make the information available.

 

Enrolment record addendum for children’s services

 

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 children's services may use this form to collect the child's enrolment information as required in Childrens Services Regulations 2020

 

Child’s name:

     

Date of birth:

  

Health information

Does your child have any special needs?   [ ] Yes [ ] No

 

If yes please provide 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 [ ] No

Does your child have an auto injection device (eg EpiPen®)?   [ ] Yes [ ] No

Has the anaphylaxis medical management plan been provided to the service?   [ ] Yes [ ] No

Has a risk management plan been completed by the service in consultation with you?   [ ] Yes [ ] No

 

In the case of anaphylaxis you will by 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 child’s enrolment form. More information can be found at www.education.vic.gov.au/anaphylaxis

Does your child have a child health record? (If yes, please provide to the service for sighting)   [ ] Yes [ ] No

 

Child health record means a record that documents a child’s health and development assessments and immunisations.

Name and position of person at the children’s service who has sighted the child’s health record

Name:

     

Position:

 

 

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 will immediately inform the children’s service in the event of any change to this information.

 

Parent’s 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 Children’s Services Regulations 2020 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.

 

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 Children’s Services Act 1996 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.

 

Confidentiality of enrolment records

The proprietor of the children’s service must ensure that information in the child’s 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 authorised by the parent or prescribed in the Children’ Services Regulations 2020