Children's Information

Child's Name



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. 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





Postal address if different


Home phone


Work phone

Place of employment

Family CRN

Number of children in CCB funded care

Will you be claiming the child care subsidy
Yes (Parent and child CRN’s must be provided in order to claim CCS.)No (Full fee will be charged)

Secondary Parent / Guardian / Partner

Parent's Name





Postal address if different


Home phone


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


Relationship to Child

Home phone


Work phone

Person 2

Full Name


Relationship to Child

Home phone


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:

Proposed Start Date

All bookings and cancellations are required in writing (not text message) to the Administration office. You can communicate bookings and cancellations via email or through our website bookings tab at or in the parent communications book located at the sign in desk at each of our centres.

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:

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?
Yes (See below)No

If yes, your enrolment cannot be processed until you supply a copy of the Medical Health Plan or a detailed Action Plan along with completing our Risk Minimisation & Communication Plan with the centre Co-ordinator.

Until you have met with the Centre Co-ordinator and completed the required documentation we are unable to complete your enrolment and make bookings for your child.

When we receive this enrolment the centre Co-ordinator will be informed and they will contact you to make an appointment to attend the centre and complete the Risk Minimisation & Communication Plan.

Please bring to the meeting your Medical Health Plan or Detailed Action Plan.

Please read our Medical Conditions and Communication Policy.

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



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.

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?

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:

Special Considerations

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.

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 agree all details provided are true & correct
  • I authorise Community OOSH Services to seek information from my child’s school regarding additional information pertaining to their well being and Enrolment
  • 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 and company Facebook page. 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 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
  2. Parent Guide (found on our website at
  3. Policies in Practice (found on our website at
  • I agree to pay my account in full each month. Fees for all services including excursions are charged to customers in arrears. A statement will be sent each fortnight that details all usage. Full payment of the account is due within 30 days of the statement date. 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 emails 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

Confrimation of Childcare Agreement

As part of your enrolment at our service we require you to confirm acceptance of the following items by signing the bottom of this enrolment form. Acceptance of these items as well as some of the other information in the enrolment form can be used as a Complying Written Arrangement for the Child Care Subsidy purposes.

  1. The arrangement is between Bassern PTY LTD (Community OOSH Services) ABN 80085051734 and the primary parent/guardian listed on this enrolment form. Our contact details are or call 0466 306 220.
  2. The date this arrangement is the date of submission written at the bottom of this enrolment
  3. The care provided is for the child listed on this enrolment form
  4. The care provided is under a casual agreement where days and sessions can be changed by the parent or guardian. All bookings for care is required in writing and will form part of this arrangement.
  5. Our sessions times of care are
    Before School Care - 6:30am to 9:00am
    After School Care - 2:45pm to 6:00pm
    Vacation Care - 7:00am to 6:0pm
  6. Our current fees are listed on our website under "Frequently Asked Questions".
    The services fees may vary from time to time and any changes will be advertised in our centres, on social media and our website with a minimum of 2 weeks notice.
    The parent or guardian understand they are liable to pay these feeds for the care of the child.

By signing the Enrolment Form you are confirming acceptance of this arrangement and the authorisations/acknowledgments section above.

Full Name



Please tick to ensure you have completed the signature field above.


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