Children's Information

Child's Name

DOB

Gender
MaleFemale

Centrelink CRN Number

*Please note that Children’s CRN number is different to the Family CRN number

School attended

Child's cultural background

Main launguage spoken at home

Childs Swimming Ability (Please select)


Parent's Information

Primary Parent / Guardian

Please note that this is the parent guardian whom the children are registered with the family assistance office. Accounts will be sent to this address. We require one of the contact numbers supplied to be available for contact in an emergency and between the hours of 3:00pm and 6:00pm each day.

Parent's Name

DOB

Address

Suburb

Postcode

Postal address if different

Email

Home phone

Mobile

Work phone

Place of employment

Family CRN

Number of children in CCB funded care

Will you be claiming the child care benefit
YesNo

*Parent and child CRN’s must be provided in order to claim CCB.

Secondary Parent / Guardian / Partner

Parent's Name

DOB

Address

Suburb

Postcode

Postal address if different

Email

Home phone

Mobile

Work phone

Place of employment


Authorised Nominees

Please list the names of any person at who

  1. You authorise to be contacted and / or to collect your child in the event of an emergency where we are unable to contact you or the other primary carer listed in the PARENTS details above.
  2. Is authorised to consent to medical treatment of, or to authorise administration of medication to the child
  3. Is authorised to authorise an educator to take the child outside of the service premises

Person 1

Full Name

Address

Relationship to Child

Home phone

Mobile

Work phone

Person 2

Full Name

Address

Relationship to Child

Home phone

Mobile

Work phone

In the event of an accident or illness requiring emergency medical treatment, every effort will be made to contact the parents. However, should this prove impossible, it will be necessary for authority to be given for treatment to be undertaken.

Doctor's Name

Doctor's Phone Number

Doctor's Address

Dentist's Name

Dentist's Phone Number

Dentist's Address

Medicare Number

Private health / Ambulance Cover (If none leave Blank)


Services Required

Please select centre of interest:

Booking Frequency
PermanentCasual

Proposed Start Date

Please select days of care and services required if permanent booking has been chosen above:

After school Care
MondayTuesdayWednesdayThursdayFriday

Before School Care
MondayTuesdayWednesdayThursdayFriday

Please Note: Parents wishing to enrol their child/children in PCYC Centre must also complete a PCYC Membership Form. PCYC Membership is included in your enrolment at no additional charge. Please pick up PCYC membership form on your first visit to the centre.


Bus information and permission note (Required for after school care)

A free bus service, or transport by vehicle is provided to and from Centres for BSC and ASC programs. Fun Factory and PCYC service students who attend Mary Help, Bayldon, Sawtell, Boambee, Toormina, Tyalla, Steiner, Narranga and Christian Community Schools. Woolgoolga services students who attend Corindi, Mullaway, Woolgoolga, St. Francis Xavier and Sandy Beach Schools. Grafton Super Centre services students who attend Westlawn P.S, Grafton P.S, Grafton Infants, Sth Grafton P.S, Sth Grafton Infants, CVAS and St. Mary’s.

Please print and complete the attached bus permission note and return the document to your school.


Children's Health Information

If any of the following illnesses/conditions/allergies are applicable to your child/children please indicate by selecting the check box and providing a brief description of the details below.
AsthmaEpilepsy/SeizuresDowns SyndromeDiabetesSocio/Emotional DisorderAllergies/Risk of AnaphylaxisHearing ImpairmentVisual ImpairmentAspergersAutismA.D.D or A.D.H.DFood SensitivityCommunication DelayIntellectual ImpairmentBehavioural DisordersPhysical RestrictionsOther

Please provide childs name and condition details here:

If your child has any of these conditions please read our Medical Conditions and Communication Policy and organise a suitable time with the Centre Co-ordinator to complete the Risk Minimisation Plan.

Treatment Plan

What strategies or treatment procedures do you have in place for their condition?

Please bring to the centre additional information if required, e.g Asthma action plan, Epipen procedure, medication etc.

Does your child/ren have a school Medical Health Plan?
YesNo

If yes, you will need to supply 2 copies of the Medical Health Plan or a detailed Action Plan PRIOR to your child attending.

PLEASE NOTE: This document is essential for enrolment and your childs health and safety

Parent(s)/Guardian(s) additionally give permission for Community OOSH Services staff to speak to my child/rens school regarding the Medical Health Plan.

PARENTS ARE RESPONSIBLE FOR SUPPLYING ALL TREATMENT MEDICATIONS eg Asthma inhalers, Epipen, medications.

Medication

Will your child require any medication to be administered by staff during the program?
YesNo

If yes, you will need to complete an ADMINISTRATION of MEDICINE AUTHORITY FORM with the supervisor. Ensure that medication is handed to the supervisor in a safe container. DO NOT LEAVE IN CHILDS BAG.
Please list the details and dosage of the medication below.

Additional Needs

Does your child/ren have any difficulties or disabilities which may require additional assistance or support in order for them to participate in the program?
YesNo

If yes, please provide details below:

Does your child receive additional aide/support during school time?
YesNo

If yes, your child's position may be contingent to our service accessing adequate support from Mid North Coast Inclusion Support Service (ISS). A risk assessment will be completed PRIOR to your child's enrolment to determine support required. Please ask staff for an Additional Programming Information Sheet as additional support, if required, must be approved by ISS PRIOR to attendance. Please be advised ISS approval may take up to 8 weeks following submission of application.

Please provide details:

Special Considerations

Are there any special considerations for you child. Eg Cultural or religious considerations or dietary requirements. Please list any special considerations here

Immunisation

In order to conform to Government regulations, we need to ascertain the immunisation status of your child/ren.

Please supply evidence of an immunisation record for each child. You can provide either copies of your Blue Book or a letter from your Doctor.

Alternatively, you can call the immunisation register on 1800 653 809 to obtain the information or visit the website here.


Access/Custody Information (If Applicable)

Community OOSH Services require details of any court 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 and any orders relating to the child’s residence or the contact with a parent or other person.

Name of Child

Name of Custodial Parent

Outline of Terms and Conditions

Expiry Date

COURT CUSTODY ORDER TO BE SIGHTED – Provide copy of court order to centre Co-ordinator that will be signed by both the Co-ordinator and the parent. No natural parent can be refused the right to collect a child unless a Court Custody Order is in place and sighted by the Management of Community OOSH Services.


Auhtorisations/Acknowledgments section

Child Name

  • I authorise for a Community OOSH Services educator to collect my child from school if After School Care is required
  • I authorise for a Community OOSH Services educator to transport my child to school if Before School Care is required
  • I authorise for a Community OOSH Services educator to seek medical attention for my child in the event of an accident / emergency from a registered medical practitioner, hospital or ambulance service
  • I authorise Community OOSH Services to arrange transportation of my child by an ambulance service if required.
  • I have read the medical conditions & communications policy and agree to the conditions set out in these policies.
  • I accept that Community OOSH Services staff and directors will not be held responsible for any financial responsibilities from injuries sustained by my child / children listed on this form
  • I Authorise for the Co-ordinator / director to administer one dose of panadol to my child in the event staff are unable to contact either Parent / Guardian listed on this form
  • I understand that as part of the education program of the Centre I authorise for my child to participate in excursions from the Centre within the local community. I acknowledge that it is my responsibility to be aware of the programmed excursions and the activities involved with the excursions. I further indemnify Directors and Employees from all actions, costs, claims and demands which may arise directly or indirectly from participation in an excursion by the said child out of the centre grounds.
  • I authorise for the educators at the centre to take photographs and videos of my child involved in play experiences for purposes of promoting the service as a high quality Centre. This involves Accreditation and Displays within the same, and inclusion on our website. I also give permission for the staff to display my children's date of birth on a Birthday Chart.
  • I authorise for my child/children to watch G and PG (parental guidance) rating videos, DVDs and Electronic Games whilst at the OOSH Centre.
  • I authorise for educators to assist my child/children to apply sunscreen or insect repellent as required.
  • I agree to contact Centrelink and nominate Community OOSH Services as the provider to receive the 50% child care rebate.
  • I acknowledge the program or excursions may vary occasionally and that any change will be noted daily on the front communications boards at each centre. I authorise for my child to participate in additional days programmed ie Pupil Free Days, Public Holidays if required
  • Should I have a grievance, I agree to follow the services grievance policy located on the Community OOSH Service website. I acknowledge that my child's position at OOSH may be jeopardised if I use any form of social media to address concerns.
  • I have read and agreed to the following policies pertaining to Community OOSH Services
  1. Behaviour Management Policy (found on our website at www.communityoosh.com.au)
  2. Parent Guide (found on our website at www.communityoosh.com.au)
  3. Policies in Practice (found on our website at www.communityoosh.com.au)
  • I agree to pay my monthly account in full each month. Fees for all services including excursions are charged to customers in arrears. A statement will be sent each month that details all usage. Full payment of the account is due each month within 30 days of the statement date. Fun factory (Toormina), PCYC and Korora statements are produced at the end of each month while Woolgoolga and Grafton statements are produced on the 15th of each month. Payments can be made by direct bank deposit, cheque or credit card payments over the phone to our administration area. In the event that my account may fall into arrears and no communication has occurred to make arrangements to settle the debt, the Community OOSH Services administrator will make every attempt to retrieve the fees (i.e two reminder letters and a telephone call). In the event the account remains unsettled and fees outstanding, they will release my details to a debt recovery officer
  • I will provide to Community OOSH Services evidence of an immunisation record for each child listed on this form

Full Name

Date

Signature


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