Centrelink CRN Number
*Please note that Children’s CRN number is different to the Family CRN number
Child's cultural background
Main launguage spoken at home
Childs Swimming Ability (Please select)
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.
Postal address if different
Place of employment
Number of children in CCB funded care
Will you be claiming the child care benefit
*Parent and child CRN’s must be provided in order to claim CCB.
Please list the names of any person at who
Relationship to Child
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 Phone Number
Dentist's Phone Number
Private health / Ambulance Cover (If none leave Blank)
Please select centre of interest:
---Korora (Korora Public School)Fun Factory (5 Craft Close, Tormina)PCYC (Bray Street, Coffs Harbour)Woolgoolga (8 Hawke Drive)Grafton Super Centre (295 Hoof Street, Grafton)
Proposed Start Date
Please select days of care and services required if permanent booking has been chosen above:
After school Care
Before School Care
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.
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.
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.
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?
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.
Will your child require any medication to be administered by staff during the program?
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.
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?
If yes, please provide details below:
Does your child receive additional aide/support during school time?
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:
Are there any special considerations for you child. Eg Cultural or religious considerations or dietary requirements. Please list any special considerations here
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.
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
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.
6658 9757 / 0466 306 220