Enrolment Form Port Explorers Out of School Hours Care January 2017

Enrolment Form After

School Hours Care CHILD’S DETAILS

Centrelink CRN No.: ...................................

Child’s Surname: ........................................

First Name: .............................................................

Address: ……………………………………………………………………. Postcode:………. Date of Enrolment: .....................................

Date of Birth: ..............................................

Date of first attendance: ............................

Religion: .....................................................

Age at date of first attendance: .................

Male or Female: ...........................................

CARE REQUIRED CODE: .......................... q Before School q Vacation Care

q After School

Mon. ̈ ̈

Tues. ̈ ̈

Wed. ̈ ̈

Thurs. ̈ ̈

Frid. ̈ ̈

4EndeavourStreet@PortDouglasStateSchool(RightsideofC&KKinderbuilding)

Ph:(07)40985793E:portexplorersoshc@outlook.com

www.portexplorers.com.au

Enrolment Form Port Explorers Out of School Hours Care January 2017

PARENT’S DETAILS Centrelink CRN No:____________________

Mother’s Surname: ........................................

D.O.B: ……/……./………. First Name: ...................................................

Address: ............................................................................................................................ Telephone No.: .............................................

Mobile No: ....................................................

Place of work: ...............................................

Work Telephone No: .....................................

Email address: ................................................................................................................... Centrelink CRN No:____________________ D.O.B: ……/……./………… Father’s Surname: .......................................

First Name: ...................................................

Address: ............................................................................................................................. Telephone No: ..............................................

Mobile No: ....................................................

Place of work: ...............................................

Work Telephone No: ....................................

Email address: ...................................................................................................................

(Must have D.O.B for parent registering for Child Care Benefit - CCB)

Enrolment Form Port Explorers Out of School Hours Care January 2017

FAMILY HISTORY People living in the household

Name D.O.B. Information Regarding Member ...................................... ……………….. ....................................................................... ...................................... ……………….. ....................................................................... ...................................... ……………….. ....................................................................... ...................................... ……………….. ....................................................................... Are there any special requirements for the child (cultural or religious observances)? YES / NO If yes, please give details: ..................................................................................................... Are there any languages other than English spoken in the household? YES / NO If yes, please give details ...................................................................................................... EMERGENCY CONTACTS 1. Name: ......................................................

Relationship: ..................................................

Address: ................................................................................................................................ Telephone No: ...............................................

Mobile No: .....................................................

2. Name: ......................................................

Relationship: ..................................................

Address: .................................................................................................................................. Telephone No: ...............................................

Mobile No: .....................................................

Doctor’s Name:………………………… Medical Centre Name: ………………………………. Telephone No:………………………………… Medicare No: . . . . . . . . . . . . . . . . . . . . . . . . . . . Ambulance: Are you a subscriber to the Queensland Ambulance? YES / NO Doctor: Should your own doctor be unable, would you consent to and accept charges

for a doctor to call, if deemed necessary? YES / NO

Enrolment Form Port Explorers Out of School Hours Care January 2017

PEOPLE AUTHORISED TO TAKE CHILD FROM THE CENTRE 1. Name: ......................................................

Relationship: ..................................................

Address: .................................................................................................................................. Mobile No: ..................................................... 2. Name: .......................................................

Relationship: ..................................................

Address: .................................................................................................................................. Mobile No: ..................................................... Do both parties have legal custody of the child? YES / NO If no, who does? ..................................................................................................................... Are there any court orders affecting the child? YES / NO If yes, please give details: ....................................................................................................

(The office will need a copy of legal documents to keep in your child’s file.)

PERSONS NOT AUTHORISED TO TAKE CHILD FROM THE CENTRE 1. Name: .....................................................

Relationship: ..............................................

2. Name: .....................................................

Relationship: ..............................................

SOCIAL EXPERIENCES Does your child have any specific fears or phobias? YES / NO If yes, please give details: ...................................................................................................... Please list any known allergies (food, sunscreen, animals etc.) YES / NO If yes, please give details: …………………………………………………………………………. Has your child had any serious illnesses or accidents? YES / NO If yes, please give details: ...................................................................................................... Has your child ever been hospitalised? YES / NO If yes, at what age: …………… Reason being: ................................................................... Is your child at present under any medical treatment? YES / NO If yes, please give details: ......................................................................................................

Enrolment Form Port Explorers Out of School Hours Care January 2017

Does your child suffer from any physical or intellectual disabilities including Communication Needs, Mobility Needs, Interpersonal Needs? YES / NO If yes, please give details: ………………………………………………………………. IMMUNISATION Has your child received the appropriate vaccines? YES / NO Is there anything else about your child that you feel we should know in order to provide ‘Quality care’ for your child? YES / NO If yes, please give details: …………………………………………………………….... SECURITY BOND I understand that as per Centre Policy, I must pay $100 per child in care to be kept by Centre as a Bond which will be refunded to me on notified departure of care providing that there is not an outstanding balance to my account. Name: ….............................................. Signature: ……………………… Date: ……………………………. Confirmation of Payment:(Office Use Only) ………………. APPLICANT’S DECLARATIONS I declare that the statements made in this application form to be true and correct. Furthermore, I have read the Centre’s Parents Information Booklet, Policies and Procedures and agree to abide by conditions of use within the Centre and do accept such responsibilities as enrolment at the Centre imposes. I understand that if I withdraw my child from the centre and have an outstanding account and do not clear this balance within 14 days of leaving the centre my details will be passed onto the centre debt collection agency. Please be aware that any costs associated with the collection of the debt will be added to your account. Name: ….................................................... Signature: ……………………………………… Date: ……………..

Enrolment Form Port Explorers Out of School Hours Care January 2017

AGREEMENT FORM

1. PERMISSION FOR STAFF TO ACT IN CASE OF EMERGENCY OF ACCIDENT

Although every care will be taken of your child while at OSHC, the staff can in no way be held responsible for any accident which may occur. In the event of an accident or illness requiring emergency medical treatment, every effort will be made to contact the parents before such treatment is sought. However, should this prove impossible, it will be necessary for authority to be given for the treatment to be undertaken. Parents are asked to complete and sign the following. I, …………………………………… authorise the staff at Port Explorers OSHC to seek emergency medical treatment for my child ……………… should this be considered necessary. Parent/Guardian’s Signature: ………………....……………… Date: ................... Witness’ Signature: ....................................

2. PERMISSION FOR CHILD TO HAVE SUNSCREEN APPLIED BY STAFF DURING

THE DAY

I DO / DO NOT give permission for my child to have sunscreen applied to them throughout the day. Parent/Guardian’s Signature: …………………………………….

MEDICAL TREATMENT PERMISSION FORM In the case of high fever or your child is ill, I give permission to the appropriate staff to administer an initial dose of Panadol to my child. I understand that I will be contacted by staff in the event that my child is suffering with symptoms. Parent/Guardian’s Signature: ...................................................

Permission to Take Photo/Video Footage I give permission for centre staff to take photos of my child during their daily routine and at special events. These photos may be displayed within the centre and used in promotional materials such as newsletters and the Port Explorers Website/Facebook site. I give permission for my child to have their photo taken or for my child to be videoed for the above purposes.

Enrolment Form Port Explorers Out of School Hours Care January 2017

Parent/Guardian’s Signature: ……………………………………..

Parent Evaluation Form.

Thank you for taking the time to fill out the enrolment form. As part of our on going service,

we now ask for a few more minutes of your time. This evaluation has been developed to

ensure that the best process is being used when enrolling families into our care. We

appreciate any questions, comments, concerns or improvements.

Please complete the following questions. 1/ Your first impressions of the centre. _____________________________________________________________________________________________________________________________________________________________________________________________________________________ 2/ Your first impressions of the staff and Management. _____________________________________________________________________________________________________________________________________________________________________________________________________________________ 3/ Did the centre have an aesthetic feel about it? _____________________________________________________________________________________________________________________________________________________________________________________________________________________ 4/ Was your induction process informative? _____________________________________________________________________________________________________________________________________________________________________________________________________________________ 5/ Was there enough information given to you about the service, it’s staff and it’s policies and procedures? _____________________________________________________________________________________________________________________________________________________________________________________________________________________ Please write any questions, comments, concerns or improvements. We are available at any time to discuss these with you. ___________________________________________________________________________

_______________________________________________________________________

Enrolment Form Port Explorers Out of School Hours Care January 2017