SURFCOAST VACATION CARE PROGRAM ENROLMENT FORM SEPTEMBER/OCTOBER 2012

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. Primary Parent First Name & Date of Birth: ______________________________________________________________________ Other Parents Name & Date of Birth: ___________________________________________________________________________ Any Other Surname Used: Y or N Home Address: If yes please provide surname: __________________________________________________ _________________ ______________________________________________________________________ ___________________________________________________________________________ Telephone: (H) (W) (M) _____________________

Name of another person to contact in case of emergency, if you are unable to be contacted: Name: Telephone: ___________________________________________________________________________ (H) (W) (M) ______________________

CHILD/CHILDRENS REGULAR SCHOOL: CHILD/CHILDREN ATTENDING THE PROGRAM: 1. Name: YES/NO 2. Name: YES/NO 3. Name: YES/NO 4. Name: YES/NO

_________________________________________________________________

________________________ DOB: _______ CRN:

Has your child been immunised?

________________________ DOB ________ CRN:

Has your child been immunised?

________________________ DOB: _______ CRN:

Has your child been immunised?

________________________ DOB ________ CRN:

Has your child been immunised?

Are your children from a non English speaking background? YES/NO

YES NO

Are they Aboriginal/Torres Strait/South Sea Islanders?

Do your children have any special requirements ie. religion, food, etc? 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 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: ____________________ 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. No spending money allowed on excursion days. Tell parent - Y 14. Are there any special access/custody arrangements? Y / N If yes please advise the service in writing.

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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. 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 local 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 National Quality Framework 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 THE PROGRAM COMMENCES. IF NOT SIGNED WE CANNOT ACCEPT YOUR BOOKING.
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SURFCOAST VACATION CARE PROGRAM BOOKINGS

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

MON 24th

TUES 25th

WED 26th

THURS 27th

FRI 28th

DATES

NAMES OF CHILDREN ATTENDING WEEK 2

REGULAR PROGRAM (please tick)

BIG DAY OUT PROGRAM (please tick)

MON 1st

TUES 2nd

WED 3rd

THUR 4th

FRI 5th

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