ROXBURGH HOMESTEAD BEFORE & AFTER CARE ENROLMENT 2013
Fields marked **MUST be completed for administration purposes.
Children’s Information –
Family Name………………………………………. Given Names…………………………………………Year Level 2013…………………….Age…………
Date of Birth**…………………………………….Sex of child**………………………………………..Centrelink CRN………………………………………
Is the child of Aboriginal and/or Torres Strait Islander origin** No……..Yes……..
Does the child have a developmental delay or disability including intellectual, sensory or physical** No……… Yes……..
Has the child been fully immunised **No……..Yes…….. Does your child have an exemption…………………………………………………….
Family Name……………………………………….Given Names…………………………………………Year Level 2013…………………….Age………….
Date of Birth**…………………………………….Sex of child**………………………………………..Centrelink CRN………………………………………
Is the child of Aboriginal and/or Torres Strait Islander origin** No……..Yes……..
Does the child have a developmental delay or disability including intellectual, sensory or physical** No……… Yes……..
Has the child been fully immunised **No………..Yes………..Does your child have an exemption……………………………………………….
Family Name………………………………………..Given Names…………………………………………Year Level 2013……………………Age…………
Date of Birth**…………………………………….Sex of child**………………………………………..Centrelink CRN……………………………………..
Is the child of Aboriginal and/or Torres Strait Islander origin** No……..Yes……..
Does the child have a developmental delay or disability including intellectual, sensory or physical** No……… Yes……..
Has the child been fully immunised **No………..Yes……….. Does your child have an exemption……………………………………………….
Parent/Guardian Information –
Parent/Guardian claiming Centrelink – PLEASE NOTE – ALL CRN’S MUST BE UNIQUE.
Family Name………………………………………..Given Names…………………………………………Relationship………………………………………….
Address…………………………………………………………………………………………………………………………………………………………………………..
Phone No’s – Home……………………………….Mobile………………………………………………….Work…………………………………………………..
Claiming Parent Date of Birth**………………………………………..Claiming Parent CRN**……………………………………………………………..
Email Address………………………………………………………………………………………………………………………………………………………………….
Second Parent –
Family Name………………………………………..Given Names…………………………………………Relationship…………………………………………..
Address…………………………………………………………………………………………………………………………………………………………………………..
Phone No’s – Home……………………………….Mobile…………………………………………………Work…………………………………………………….
The above child/ren reside with – Both Parents………………………….Mother……………………………Father……………………………………..
People authorised to collect your child –
Family Name…………………………………………Given Names………………………………………….Relationship………………………………………..
Phone No’s – Home……………………………….Mobile…………………………………………………..Work………………………………………………….
Family Name…………………………………………Given Names………………………………………….Relationship………………………………………..
Phone No’s – Home……………………………….Mobile…………………………………………………..Work………………………………………………….
Are there any special access/custody arrangements – Yes……….No……….If yes, please record details below –
………………………………………………………………………………………………………………………………………………………………………………………
If court orders exist relating to the child/ren, please provide the co-ordinator with a copy to attach to this enrolment.
Health/Medical Information –
Doctor/Medical Centre………………………………………………………………………………….Phone No……………………………………………………
Does your child/ren suffer from any medical condition that Staff need to be aware of, eg. Asthma, Allergies, etc.**
If yes please record detail over page –
……………………………………………………………………………………………………………………………………………………………………………………..
Anaphylaxis –
Has your child been diagnosed at risk of anaphylaxis** Yes…………..No……………
Does your child have an auto injection devise eg. Epipen, Anapen. Yes……………No………….. Which one…………………….
Has an anaphylaxis medical management plan been provided to the service. Yes…………..No……………
Cultural Information – Language spoken at home…………………………………………………..Interpreter required? Yes………No………….
Relevant cultural details, food restrictions, activities etc……………………………………………………………………………………………………..
General Information about your children –
Likes/Dislikes………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….
Family Structure –
……………………………………………………………………………………………………………………………………………………………………………………..
Program Usage Parental Permission**
Before Care After Care Please indicate below if you give permission for
Monday ……………… …………… your child to participate in the following –
Tuesday ……………… …………… Face Painting …………….
Wednesday ……………… …………… PG rated movies …………….
Thursday ……………… …………… Being Photographed …………….
Friday ……………… ……………
Please Note – any afternoon sessions marked will be
charged for unless advised of non-attendance before 9.00am.
Casual ……………… ……………
Please Note – Afternoon sessions booked after 9.00am on
day of expected attendance will incur a $2.00 surcharge. Starting Date – ……………………………………..
TERMS AND CONDITIONS – Please read carefully before signing.
I………………………………………………………………………….(please print full name), approve of the enrolment terms and conditions and agree to abide by the requirements of the Out of School hours Policy and Procedures document.
Signature**……………………………………………………………………..Date……………………………………………………………………..