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Contact Us: 03 9305 1688 | roxburgh.homestead.ps@edumail.vic.gov.au

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, the undersigned, (a person with lawful authority of the child/ren referred to in this enrolment, declare that the above information is true and correct and undertake to immediately inform the Program in the event of any change to this information.
  • I agree to pay my fees regularly and on time; I understand that constant failure to pay my account in a timely manner will result in my child/ren being unable to attend.
  • In the event of any unforseen accident or illness, I authorise the Co-ordinator or person in charge, to obtain such medical assistance that may be required and agree to meet any expenses incurred for such treatment.
  • I will ensure that my child is collected on time every night; I understand that there will be late fees incurred if I fail to do so.  I also understand that constant failure to collect my child on time will result in exclusion from the program.
  • The Program will not be held responsible for any special/personal belongings while attending this program.  It is strongly recommended that these items be left at home.
  • I fully understand that if my child continuously misbehaves, and after behaviour guidance procedures have been implemented, I will be notified and my child will be removed from the program.
  • I AGREE TO INFORM PROGRAM STAFF OF ANY ABSENCE and to sign attendance sheets for all sessions.
  • I acknowledge that my child will not attend the program if suffering from an infectious or contagious disease.
  • If we have an incidence of an infectious or contagious disease and your child has not been fully vaccinated, they will be required to stay away from the program.
  • In the event that my child is injured or becomes ill during the program, either myself or an authorised person shall collect the child as soon as practical.

 

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……………………………………………………………………..