SURFCOAST VACATION CARE PROGRAM ENROLMENT FORM JANUARY 2012

Parent/Guardian Surname: Parent/Guardian CRN:_______________

PLEASE NOTE: If you are a new family to the s ervice a customer refer ence number (CRN) for the family and children are now required befor e any bookings can be process ed. To obtain CRNs conta ct the Family Assistance Office on 136150. Primary Parent First Name & Date of Birth:_________________________________________________________________________ Other Parents Name & Date of Birth:______________________________________________________________________________ Any Other Surname Used: Home Addres s : Y or N If yes please provide surname:____________________________________________________ _______________________________________________________________________________________ ______________________________________________________________________________ Telephone: (H) (W) (M) _________

Name of another person to conta ct in ca se of emergen cy, if you are unable to be contact ed: Name: Telephone: ______________________________________________________________________________ (H) (W) __________________________ (M) __________

CHILD/CHILDRENS REGULAR SCHOOL: CHILD/CHILDREN ATTENDING THE PROGRAM:

1. Name: _______________________DOB:_________ CRN: immunised? YES/NO 2. Name: __________________________DOB__________CRN: immunised? YES/NO 3. Name: __________________________DOB:_________CRN: immunised? YES/NO 4. Name: __________________________DOB__________CRN: immunised? YES/NO Are your children from a non English speaking background? YES/NO YES NO

Has your child been Has your child been Has your child been Has your child been Are they Aboriginal/Torres Strait/South Sea Islanders ? If yes please list in the space provided.

Do your children have any special requirements ie. religion, food, et c? YES/NO

Please list any medical condition or allergies for ea ch 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 doct or and an up to date Adrenaline Auto Injection Device. Your child will not be allowed to attend if the plan and the device are not brought to the program each day your child attends. Name: Name: Name: ___ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Medical Condition: ___ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Medical Condition: Doctor : Doct or: Doctor : PH: PH: PH:

___ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Medical Condition:

Name:

___ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Medical Condition:

Doctor :

PH:

PLEASE ANSWER THE FOLLOWING QUESTIONS 1. Ar e 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 register ed 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 can cellation policy. Y 9. Please ensure your child brings along their own named water bottle. Y 10. Please ensure your child brings enough food and drink to last all day. Y

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11 . Please ensure no food with nut products are brought into the program due to some children being at risk of anaphylaxis. - Y 12. All children must bring a broad brimmed hat. Y 13 . NO spending money allowed at all during program, including excursion days. Y 14. Are there any special acces s/ cust ody 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. 17. We no longer take phone bookings PLEASE COMPLETE ENROLMENT RECORD ADDENDUM ON THE NEXT PAGE. FURTHER INFORMATION ABOUT YOUR CHILDREN TO SHARE WITH OUR PROGRAM STAFF

Chil ds names Are ther e any activi ti e s that you r chil d part icu l a r l y enjoys or has a special inte re st in? Are ther e any other special cons ider at io n s the staf f wil l need to be aware of to ensu r e the partic ipa tio n of your chil d in all activi ti e s? What are the iden ti f i e d goal s for your chil d s incl us i on into the school hol iday progra m? What is a cal mi n g activ it y for you r chil d? What is your chil ds favou r it e activi ty to do at school? Any fur t he r comme n t s?

PRI VACY POLICY The Surfcoast Shire consider s 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 & Recr eation Centre will only use the personal information on this form for the purpose of statistics and child car e benefit requirements. The information will not be dis closed to any other party unless Council is required to do so by law. You can view and change the information by conta cting 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 cos ts 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 expens es attached to su ch treatment. I give permission for my child/ren to be taken on any ex cursions and local outings as organised by the program and to wat ch 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 absen ce 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 pra ctical. I authorise leaders to apply sunscr een to my child and to wear a hat provided by the program for use outdoors if necessary. I give cons ent to the staff to take photographs or video footage of my child during activities in the program for the National Quality Framework accr editation 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 THA T ALL REQUIRED AREA S ARE SIGNED ON THIS ENROLMEN T FORM BEFORE THE PROGRAM COMMEN CES . IF NOT SIGNED WE CANNOT ACCEPT YOUR BOOKIN G.

NO NUTS
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THIS FACILITY IS TOTALLY NUT FREE. NO NUTS OR NUT PRODUCTS DUE TO A NUMBER OF CHILDREN AT RISK OF ANAPHYLAXIS
SURFCOA S T VACATION CARE PROGRA M BOOKIN G S
DATES MON 2nd TUES 3 rd WED 4 th THURS 5 th FRI 6 th DATES MON 9th TUES 10th WED 11th THUR 12 th FRI 13 th DATES MON 16th TUES 17th WED 18th THUR 19th FRI 20th DATES MON 23rd TUES 24th WED 25th NAMES OF CHILDREN ATTENDING WEEK 4 REGULAR PROGRAM (please tick) BIG DAY OUT PROGRAM (please tick) NAMES OF CHILDREN ATTENDING WEEK 3 REGULAR PROGRAM (pleas e tick) BIG DAY OUT PROGRAM (please tick) NAMES OF CHILDREN ATTENDING WEEK 2 REGULAR PROGRAM (pleas e tick) BIG DAY OUT PROGRAM (please tick) NAMES OF CHILDREN ATTENDING WEEK 1 NO PROGRAM TODAY REGULAR PROGRAM (pleas e tick) BIG DAY OUT PROGRAM (please tick)

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THUR 26th FRI 27th

NO PROGRAM TODAY

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