ENROLMENT FORM

It is essential that you take the time to complete ALL details in this enrolment form (below).

Confidentiality and Privacy: The personal information requested on this form is being collected for the purpose of facilitating a child care placement in accordance with Education and Care Services National Law and Regulations. The personal information will be used solely for this purpose or directly related purposes. Relevant information will be shared with educators at this service to assist them in best meeting the needs of your child.

Welcome to Viewbank Early Childhood Centre

We look forward to working with your child and family. To get started, we need to collect some important information that helps to promote the safety and wellbeing of all children at our services. Please read this form, fill in the parts that are relevant to you and get in touch with us if you have any questions.

Below are the items you will need to complete this form . .

• Immunisation History Statement
• Child's Customer Reference Number (CRN)
• Child's Medicare Number
• Parent's Customer Reference Number (CRN)
• Child's doctors details
• Contact information for emergency contacts
• Custody or parenting orders (if required)
• Child Health Record Book
• Coloured copy of Anaphylaxis/Allergy Action Plan signed by doctor (if required)

This form must be completed by a parent or guardian with 'parental responsibility' of the child. The information in this enroment record is required by the Regulatory Authority - The Department of Education and Early Childhood Development, and under the National Law and Regulations, and therefore all sections of the Enrolment Record MUST be completed. 'Parental Responsibility' refers to 'all the duties, powers, responsibilities and authority which, by law, parents have in relation to children.'

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CHILD’S FULL NAME

 

Child CRN

 

Parent CRN

 

Are you registered for CCS?

Yes  No 

Who is CCS registered with?

 

How many children are in approved care (including before and after school)

 

Information about the child 

Date of birth

[Select date →]

Gender

Male  Female 

Home address

Country of Birth

[Select] Afghanistan Akrotiri Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Ashmore and Cartier Islands Australia Austria Azerbaijan Bahamas, The Bahrain Bangladesh Barbados Bassas da India Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burma Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Clipperton Island Cocos (Keeling) Islands Colombia Comoros Congo, Democratic Republic of the Congo, Republic of the Cook Islands Coral Sea Islands Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Dhekelia Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Europa Island Falkland Islands (Islas Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern and Antarctic Lands Gabon Gambia, The Gaza Strip Georgia Germany Ghana Gibraltar Glorioso Islands Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See (Vatican City) Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Jan Mayen Japan Jersey Jordan Juan de Nova Island Kazakhstan Kenya Kiribati Korea, North Korea, South Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States of Moldova Monaco Mongolia Montserrat Morocco Mozambique Namibia Nauru Navassa Island Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paracel Islands Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands Spain Spratly Islands Sri Lanka Sudan Suriname Svalbard Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tromelin Island Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Venezuela Vietnam Virgin Islands Wake Island Wallis and Futuna West Bank Western Sahara Yemen Zambia Zimbabwe  

Language(s) spoken at home

 

Cultural background of child

 

Family

 

Information about the child’s parents or guardians

Parent/Guardian (1) 

Name (1)

 

Date of birth (1)

 

Health Care Card (1)

 

Address (1)

Mobile telephone (1)

 

Home telephone (1)

 

Work telephone (1)

 

Email (1)

 

Work address (1)

Occupation (1)

 

Work hours (1)

 

Does the parent live with this parent/guardian (1)

Yes  No 

Parent/Guardian (2) 

Name (2)

 

Date of birth (2)

 

Health Care Card (2)

 

Address (2)

Mobile telephone (2)

 

Home telephone (2)

 

Work telephone (2)

 

Email (2)

 

Work address (2)

Occupation (2)

 

Work hours (2)

 

Does the parent live with this parent/guardian (2)

Yes  No 

Court orders, parenting orders or parenting plans relating 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?

No, Proceed to the next section  Yes, Please complete the following steps 

1. Please provide original court order/s, parenting orders or parenting plans to the Centre for sighting

2. If these orders:

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

• Authorise the taking of the child outside the Centre by a staff member of the Centre;
• Consent to the medical treatment of the child;
• Request or permit the administration of medication to the child;
• Collect the child from the Centre, AND/OR

b) Give these powers to someone else,

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

[ADMIN ONLY] Court Orders/Parenting plans sighted/copied

 

Authorised Persons – Other persons you authorise to be NOTIFIED IN AN EMERGENCY

There may be times when the child is involved in an emergency situation such as an accident, injury, trauma or illness and the parents or guardians cannot be contacted. To deal with these emergency situations, as parents/guardians, you authorise the Centre to notify one of the following people who are authorised to collect and care for the child after an accident, injury, trauma or illness. In the event of the child requiring medical treatment or administration of medication, the following persons are also authorised to consent to the authorisation of medical treatment or administration of medication. These persons may also authorise an educator to take the child outside of the Centre should the parents/guardians of the child not be able to be contacted for authorisation. Please provide at least 1

Authorised person (1) 

Authorised person name (1)

 

Address (1)

Mobile telephone (1)

 

Home telephone (1)

 

Work telephone (1)

 

Relationship to child (1)

 

Authorised person (2) 

Authorised person name (2)

 

Address (2)

Mobile telephone (2)

 

Home telephone (2)

 

Work telephone (2)

 

Relationship to child (2)

 

Authorised Persons – Other persons you nominate to COLLECT YOUR CHILD

Your consent is required for other people to collect your child from the Centre on your behalf. In the table below, please list the details of those people you have authorised to collect your child. This list may be added to or changed as necessary. In the event that the child is not collected from the Centre and the parents/guardians cannot be contacted, this list will also be used to arrange someone to collect the child. These authorised Nominees may be the same as the 'Authorised Persons- other persons authorised to be notified in an emergency' as authorised on previous page, however their details must also be recorded on this page. Please provide at least 1 Authorised Nominee.

Authorised collection person (1) 

Authorised collection person name (1)

 

Address (1)

Mobile telephone (1)

 

Home telephone (1)

 

Work telephone (1)

 

Relationship to child (1)

 

Authorised collection person (2) 

Authorised collection person name (2)

 

Address (2)

Mobile telephone (2)

 

Home telephone (2)

 

Work telephone (2)

 

Relationship to child (2)

 

Authorised collection person (3) 

Authorised collection person name (3)

 

Address (3)

Mobile telephone (3)

 

Home telephone (3)

 

Work telephone (3)

 

Relationship to child (3)

 

Authorised collection person (4) 

Authorised collection person name (4)

 

Address (4)

Mobile telephone (4)

 

Home telephone (4)

 

Work telephone (4)

 

Relationship to child (4)

 

The above mentioned authorised nominees are NOT authorised to give consent to medical treatment of the child or to authorise an educator to take the child outside of the service. This authorisation can only be given by the parents or guardians or those nominated in the 'Authorised Persons- Other persons you authorise to be notified in an emergency.

Child’s Health & Medical Information

Child’s Immunisation Record 

Under the No Jab, No Play Requirements, we are required to request and retain immunisation status information for each child attending the Centre. Please provide your child’s up to date Immunisation statement, available from Medicare (MyGov), or ACIR to the Centre.
Each time your child receives an Immunisation, please bring their updated Statement from ACIR or MyGov.

[ADMIN ONLY] Immunisation record sighted

 

Doctor/Medical service 

Doctor/Medical service name

 

Doctor/Medical service telephone

 

Doctor/Medical serviceaddress

 

Ambulance Subscriber?

Yes  No 

Membership Number

 

Private Health Insurance?

Yes  No 

Fund Name

 

Membership number

 

Medicare Number

 

Health Record book 

Does your child have a Health Record book (a record that documents a child's health and development assessments and immunisations)?

Yes  No 

Please provide to the Centre for sighting

[ADMIN ONLY] Health Record sighted

 

Special Needs 

Does your child have any special needs?

Yes  No 

Please provide details of any special needs and any management procedure to be followed with respect to the special need.

Allergies 

Has your child been diagnosed with an allergy?

Yes  No 

Please list allergy/s below.

You MUST provide a coloured copy of your child’s current allergy action plan signed by a registered medical practitioner to administration staff for copying.
In the case of an allergy, the Centre will complete a risk management plan in consultation with you, and provide this for you to read and sign.

[ADMIN ONLY] Allergy Action plan sighted/copied

 

Anaphylaxis 

Has your child been diagnosed at risk of anaphylaxis?

Yes  No 

You MUST provide a coloured copy of your child’s current anaphylaxis action plan signed by a registered medical practitioner to administration staff for copying.
You will be provided with a copy of the Centre's anaphylaxis policy. The Centre will complete a risk management plan in consultation with you, and provide this for you to read and sign. More information is available at www.education.vic.gov.au/anaphylaxis

[ADMIN ONLY] Anaphylaxis action planb sighted/copied

 

Asthma 

Has your child been diagnosed with Asthma?

Yes  No 

You MUST provide a coloured copy of your child’s current asthma action plan signed by a registered medical practitioner to administration staff for copying.
The Centre will complete a risk management plan in consultation with you, and provide this for you to read and sign.

[ADMIN ONLY] Asthma action plan sighted/copied

 

Diagnosed Medical Conditions or Needs 

Does your child have any diagnosed medical conditions or needs) e.g. epilepsy, diabetes, coeliac or any other specific medical conditions) which are relevant to the care of your child?

Yes  No 

Please list the medical condition(s) below.

You MUST provide a coloured copy of your child’s medical conditions management plan signed by a registered medical practitioner to administration staff for copying.
Where your child has a diagnosed medical condition, the Centre will complete a risk minimisation plan in consultation with you, and provide this for you to read and sign.

[ADMIN ONLY] Medical conditions management plan sighted/copied

 

Dietary Requirements 

Does your child have any dietary requirements which are NOT related to an allergy i.e. cultural, religious, preference?

Yes  No 

If yes, please list the dietary requirements below and the reason or them.

Information for bodies which provide funding to this service 

From time to time the Department of Education and Early Childhood Development seeks information on the characteristics of families who use this Centre. This is used in planning new policies, programs and resources to support services. To help provide accurate information, could you please answer the following questions:

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

Yes  No 

Does either parent have a disability?

Yes  No 

Is this a single parent family?

Yes  No 

Is your child of Aboriginal and or Torres Strait Islander origin?

Aboriginal  Torres Strait Islander  No 

Additional Information 

Is there anything else the Centre should know about your child? (Cultural or religious requirements, fears, favourite activities, whether they are attending another early childhood service or early intervention service etc).

Please also let us know if your child requires any alternative products to what the Centre provides e.g. their own nappies, wipes, bandaids, sunscreen etc, please list below: (if yes, please ensure these are clearly labelled and provided to your child’s room.) The Centre will apply these products unless advised in writing otherwise.

Parents/Guardians Agreement & Authorisation

Please note that your child can not be enrolled at Viewbank Early Childhood Centre unless the following agreements have been authorised by the parent or guardian (where applicable). Risk assessments and further policies can be sighted in centre/can be provided.

• I authorise/give permission for my child to join in on cooking experiences within the Centre (noting staff will observe any allergies)
• I authorise/give permission for my child to join in of Road Safety activities conducted in the Centre car park.
• I authorise/give permission for my child to join in on Therapy dog visits to the Centre.
• I authorise/give permission for my child to attend Bush Creek and park walks (when in 3&4 Year old Kinder).
• In the case of accident or other emergency resulting in the need for immediate medical attention, I hereby give my permission for the approved provider, nominated supervisor, educator or staff member to arrange for my child to seek medical treatment from a registered medical practitioner, hospital or ambulance service and/or transportation of the child by an ambulance service.
• I agree to abide by the Centre's Children's Health & Exclusion policy and realise that a medical certificate must be provided if requested, before my child can be readmitted following an infectious disease of any kind. I understand that the Director, or Responsible person acting on their behalf, reserves the right to exclude my child if the staff member considers them not well enough to attend the centre.
• A non-refundable $50 booking fee is payable upon enrolment to confirm your child’s place. For permanent bookings the full fee will be charged for all days your child is booked into the centre regardless of public holidays, family holidays, illnesses or school term breaks.
  A fee of $30 for every fifteen minutes or part thereof will be charged for children left at the centre after their agreed CWA time. Two week’s notice must be given in writing before ceasing care or payment in lieu will be charged.
• In the event of a child needing medical treatment while in the care and control of the centre, the Management reserves the right to have the child attended to by the centre’s medical advisers, at the financial responsibility of the child’s parent. Children with infectious diseases (i.e. Measles, Chicken Pox, Diarrhoea ...) are not permitted to attend the centre in accordance with the Centre's Health & Exclusion policy and the NHMRC Recommended minimum exclusion periods.
• I have read and understood the conditions of enrolment and agree to abide by them.

Photographs 

I give permission for Educators to take photos photographs of my child to be included in documentation relating to Early Years Learning Framework, program planning and individual as well as group portfolios and observations.

Yes  No 

I give permission for Educators to take photographs of my child to be used for promotional material e.g newsletters, brochures, and centrwebsite.

Yes  No