Attach

Immunisation
Statement here

Warrawee Care Centre

Enrolment Form 2014
(to be used for 2014 only)

Section 1 : PERSONAL INFORMATION

Family Name ___________________________________
Children's Names
1. ___________________________________________Date of Birth _______________CRN__________________Sex________
2. ___________________________________________Date of Birth _______________CRN__________________Sex________
3. ___________________________________________Date of Birth _______________CRN__________________Sex________
Address _________________________________________________________________________________________________

Parent and Guardian information

Full Name________________________________________________________________________________________________
Date of Birth ______________________________________________________________________________________________
Home Address ____________________________________________________________________________________________
Occupation _______________________________________________________________________________________________
Place of Employment _______________________________________________________________________________________
Contact Phone
(h) ___________________________ (w) _____________________ (mob) _____________________________
Full Name________________________________________________________________________________________________
Date of Birth ______________________________________________________________________________________________
Home Address ____________________________________________________________________________________________
Occupation _______________________________________________________________________________________________
Place of Employment _______________________________________________________________________________________
Contact Phone
(h) ___________________________ (w) _____________________ (mob) _____________________________

Parent Details for Childcare Tax Rebate

Parent linked with Family Assistance Office for Childcare Tax Rebate _________________________________________________
CRN of above parent __________________________________ Date of birth _________________________________________
Please note there will be a different CRN for the parent and for each child, ensure you do NOT use the same numbers

Correspondence for Centre invoices, newsletters, fee updates and general information
Email Address __________________________________________________PLEASE PRINT CLEARLY

Is your child the subject of any custody, parenting or access order ? Yes / No If yes, please attach copy of order
________________________________________________________________________________________________________
Cultural Background
We aim to create an environment in which each childs cultural background is respected and each childs individual identity can be
nutured. To assist us to achieve this, we ask you to complete the following questions. This includes children from Aboriginal and
Torres Strait Islander background and children from other culturally and linguistically diverse backgrounds.
Country of birth: ____________________________________
____________________________________________
(child)
(parents)
Language/s spoken: ________________________________
____________________________________________
(child)
(parents)
Childs cultural identity: ______________________________ Parents cultural background: _____________________________
Special cultural, religious or dietary considerations for the child: ____________________________________________________
Family customs or religious or cultural practices to be respected by the service: ________________________________________
_________________________________________________________________________________________________________

Warrawee Care Centre Enrolment Form 2014 (Confidential). Page 1

Section 2 : MEDICAL and HEALTH DETAILS

Medical Practitioner / Medical Service Name _______________________________________ Phone _______________________
Address _________________________________________________________________________________________________

CHILD 1: Name ________________________________________________________________________

Child's Medicare No _________________________________ Date of last tetanus injection _______________________________
Fully immunised ? Yes / No
Private Health ?
Yes / No
Immunisation Statement must be provided at the time of enrolment
please attach
Is your child on any prescribed medication ? Yes / No If yes, please complete a medication form from staff
Name of medication ___________________________________ Diagnosed condition ___________________________________
Relevant medical history (eg allergies, medication, specific needs) ___________________________________________________
________________________________________________________________________________________________________
Has your child ever been diagnosed with asthma ? Yes / No If yes,complete the asthma record from staff
Has your child ever been diagnosed as at risk of anaphylaxis ? Yes / No If yes, complete the anaphylaxis management plan
Details of child's disabilities, special needs or medical conditions__ __________________________________________________
____________________________________________________________________________________________________________________
Dietary Restrictions ________________________________________________________________________________________

CHILD 2: Name ________________________________________________________________________

Child's Medicare No _________________________________ Date of last tetanus injection _______________________________
Fully immunised ? Yes / No
Private Health ?
Yes / No
Immunisation Statement must be provided at the time of enrolment
please attach
Is your child on any prescribed medication ? Yes / No If yes, please complete a medication form from staff
Name of medication ___________________________________ Diagnosed condition ___________________________________
Relevant medical history (eg allergies, medication, specific needs) ___________________________________________________
________________________________________________________________________________________________________
Has your child ever been diagnosed with asthma ? Yes / No If yes,complete the asthma record from staff
Has your child ever been diagnosed as at risk of anaphylaxis ? Yes / No If yes, complete the anaphylaxis management plan
Details of child's disabilities, special needs or medical conditions__ __________________________________________________
____________________________________________________________________________________________________________________
Dietary Restrictions ________________________________________________________________________________________

CHILD 3: Name ________________________________________________________________________

Child's Medicare No _________________________________ Date of last tetanus injection _______________________________
Fully immunised ? Yes / No
Private Health ?
Yes / No
Immunisation Statement must be provided at the time of enrolment
please attach
Is your child on any prescribed medication ? Yes / No If yes, please complete a medication form from staff
Name of medication ___________________________________ Diagnosed condition ___________________________________
Relevant medical history (eg allergies, medication, specific needs) ___________________________________________________
________________________________________________________________________________________________________
Has your child ever been diagnosed with asthma ? Yes / No If yes,complete the asthma record from staff
Has your child ever been diagnosed as at risk of anaphylaxis ? Yes / No If yes, complete the anaphylaxis management plan
Details of child's disabilities, special needs or medical conditions__ __________________________________________________
____________________________________________________________________________________________________________________
Dietary Restrictions ________________________________________________________________________________________
Warrawee Care Centre Enrolment Form 2014 (Confidential). Page 2

Section 3 : EMERGENCY CONTACTS and AUTHORISED CONTACTS FOR COLLECTION

- The following individuals have permission to collect my child from the Centre, to be
notified of an emergency involving my child if I cannot be contacted and to authorise consent for medical treatment or administration
of medication for my child. These contacts may also authorise an educator to take the child outside the service premises if
necessary.
Emergency Contacts and Authorised

Please supply 2 names, other than the childs parents / guardians.

Name

Name

Relationship to child

Relationship to child

Contact phone

Contact phone

Address

Address

NOTE It is important that you inform the above people that you have included them as emergency contacts and that they may be
contacted in the case of an emergency, or asked to collect your child when you cannot be contacted.
Additional people who are authorised only to collect my child
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________

Section 4: FEES, CHARGES & REGISTRATION

Annual Family Registration is paid at the time of enrolment so your child will be eligible to attend

Registration Payment of $50 per family

cheque
credit card
cash
(please circle)
--------------------------------------------------------------------------------------------------------------------------------PAYMENT BY:

Bankcard

Mastercard

Visa

Card Number: ___________________________________ Expiry Date: _____________________

Cardholders Name: ______________________________ Signature: _______________________
Preferred Payment of Fees
Please use the credit card details given to debit my Centre fees at the beginning of each term and to debit any extra charges
accrued during the term
Yes / No
This is the Centres preferred method of payment and will ensure you dont accrue any late charges. All credit details are
stored securely. It remains the parents responsibility to ensure their fees are paid in the set time if credit card
authorisation isnt provided at the time of enrolment.

Who is liable for the cost of care and responsible for providing payment of the fees? _____________________________________

Under the Children and Young Persons (Care and Protection) Act 1998, Chapter 16A, information may be shared with other
prescribed agencies that relates to the current welfare, wellbeing and safety of children in our care. Staff at Warrawee Care Centre
adhere to the Privacy Act and all Centre Policies and Procedures. Staff at Warrawee Care Centre are mandatory reporters under the
Children and Young Persons (Care and Protection) Act 1998.

Warrawee Care Centre Enrolment Form 2014 (Confidential). Page 3

Section 5 : BEFORE & AFTER SCHOOL CARE BOOKING

Priority of Care
Permanent Child Care places are allocated to families based on the Centres Enrolment and Service Access policies and in
accordance with Government guidelines.
Please indicate, using the boxes below, your current family situation q Priority 1 a child at risk of serious abuse or neglect
q Priority 2 a child of a single parent who satisfies, or of parents who both satisfy, the work / training / study test.
q Priority 3 any other child.
Days of Attendance
Please indicate whether your child will be attending permanently or casually
o Casual Attendance
Casual bookings are only available if a vacancy exists as the Centre cannot exceed its licensed quota.
o Permanent Attendance
A permanent place means children attend the same days each week and 2 weeks notice in writing is required to cancel the place or
change days of attendance (if available).
Please Indicate the Days of Attendance
Mon: BSC (

Tues: BSC (

Wed: BSC (

Thurs: BSC (

Fri: BSC (

ASC (

ASC (

ASC (

ASC (

ASC (

Date of Permanent Care to Commence ____________________________________________

This will be the date you will be invoiced from and your child will appear on the Centre roll. Please advise staff if you want to pay to
hold your place if your child will not be starting care immediately. All care commencing in term 1 will be invoiced from the first day of
school.

Section 6 : AUTHORISATIONS
Application of Sunscreen and Insect Repellent
I give permission for staff or my child to apply sunscreen and insect repellant as required (if not please supply your own sunscreen)
Signed Parent/Carer 1: __________________________ Parent/Carer 2: _____________________

Asthma Authorisation (compulsory)

I give permission for staff to follow the recommended Asthma First Aid Plan if;
My child has a diagnosis of asthma and experiences asthma symptoms but does not have a completed asthma record or asthma
action plan OR my child does not have a previous diagnosis of asthma but experiences difficulty breathing while attending the
service.
Signed Parent/Carer 1: __________________________ Parent/Carer 2: _____________________

Medical and First Aid Care (compulsory)

I hereby give my permission for the staff at Warrawee Care Centre to administer first aid on my/our child if they should deem it
necessary, without obtaining my/our permission. Should at anytime the staff consider that my/our child requires medical, dental or
hospital treatment, I/we hereby consent to you obtaining such treatment from a registered medical practitioner, hospital or
ambulance service with all possible speed, at my/our expense. I/we understand that all attempts will be made to contact me/us;
however treatment will not be delayed in the event I/we can not be contacted. We consent to transportation of our child by an
ambulance service. I/we understand that relevant information on this form will be passed on to hospital/medical staff if required.
Signed Parent/Carer 1: __________________________ Parent/Carer 2: _____________________

Administration of Paracetamol Mixture

I hereby authorise the staff at Warrawee Care Centre to administer an age / weight appropriate dose of a paracetamol mixture
(Panadol / Nurofen) to my child if I am uncontactable by phone. Paracetamol may be given for a temperature higher than 38C or if a
child is in visible discomfort and/or pain.
Signed Parent/Carer 1: __________________________ Parent/Carer 2: ____________________

Warrawee Care Centre Enrolment Form 2014 (Confidential). Page 4

Administration of Allergies and Anaphylaxis Emergency Kit (compulsory)

I agree that if my child has no known allergy but appears to be having an anaphylactic reaction whilst at the service, or otherwise in
the Centres care, staff will call an ambulance and will follow the recommended treatment plan(as per Centres policy). This may
involve the administration of an epipen from the services Anaphylaxis Emergency Kit.
Signed Parent/Carer 1: __________________________ Parent/Carer 2: _____________________

Medical Conditions for display

If my child is recognised to have an action plan for a life threatening medical condition I give permission for my childs
plan to be displayed for educators and visitors to view.
Signed Parent/Carer 1: __________________________ Parent/Carer 2: _____________________

Use of Childrens Photographs, Videos and Programming Documentation

1. I agree that photographs and videos of my child taken by staff at Warrawee Care Centre may be displayed or
viewed at the service or incorporated into other childrens programming related documentation
Yes

No

(please circle)

2. I agree that photographs, videos, artwork and programming documentation (learning stories, profiles, photo
stories, program evaluations, provocations, projects) of my child taken or recorded by the staff at Warrawee
Care Centre may be used in its publications, on its website, for educational displays and in presentations for
professional development and conferences
Yes

No

(please circle)

3. I agree that programing related documentation may be electronically shared with families and may include
photos, videos and related documentation including my child. This includes documentation and group photos
in other childrens electronic journals.
Yes
No
(please circle)
PLEASE NOTE.. No documentation may be copied, reused or retransmitted without the permission of the service
Signed Parent/Carer 1: __________________________ Parent/Carer 2: _____________________

Costs of Debt Recovery (compulsory)

I expressly agree that I am liable for any recovery costs including administrative fees, debt recovery fees, solicitor fees and
disbursements incurred by Warrawee Care Centre as a result of my failure to pay the fees and charges for the service provided
within the payment terms. I accept that I may also be charged an additional fee for interest at the statutory rate recoverable in the
appropriate Court at the time prevailing however I am aware that costs incurred through Court action against me will be limited to the
fees recoverable under the State Legislation for legal cost recovery.
Signed Parent/Carer 1: __________________________ Parent/Carer 2: _____________________

Parents or Carers Declaration and Agreement (compulsory)

I understand by completing this form I am agreeing to Warrawee Care Centres policies and procedures,fees and charges. I am
aware I need to give 2 weeks notice in writing to cancel or change my before or after school care permanent bookings. A search fee
of $15 will be charged if the Centre is not notified of an after school care absence.
An administration fee of $100 will be charged if my fees are outstanding after Week 6 of each term. Late fees will be charged after
Centre closure - $25 per 15 mins of part thereof. The Centre reserves the right to refuse care for children who have outstanding
fees from previous terms. The Centre reserves the right to refuse care to children who risk the safety of themselves, other children
or Centre Staff as per Centre policies.
I understand that my childs continued enrolment at the service depends on my acceptance of Warrawee Care Centres policies and
procedures and my care will be withdrawn if I do not abide by these policies. I am aware a policy manual is available in the Centre
foyer and I must strictly comply with the Polices and Procedures at all times. The Policies and Procedures incorporate any relevant
statutory obligations imposed on the Centre and have been put in place to protect all child / children in the service.
I am totally responsible for the accuracy of the information and my compliance with the Policies and Procedures. I am totally
responsible for the suitability and actions of any person/persons whom I authorize to visit, deliver and or collect my child/children
to/from the Centre or any other place. The information provided in this enrolment record is to the best of my knowledge correct.
Signed Parent/Carer 1: __________________________ Parent/Carer 2: _____________________

Warrawee Care Centre Enrolment Form 2014 (Confidential). Page 5

Section 7: MEMBERSHIP
The Centre is an Incorporated Association ans as such, by enrolling my child in the Centre I agree to be bound by the rules of the
Association for the period of my childs enrolment. I understand that as a member of the Incorporated Association, one
representative of my childs family is entitled to voting rights at any general meeting held by the Centre and that I may be nominated
(with consent) for a position on the Management Committee at the Annual General Meeting.
Applicant Details
I, ____________________________________________________________________________________ (full name)
of ____________________________________________________________________________________ (address)
Telephone (home): _________________________________ (mobile): ______________________________________
Signed: ___________________________________

Date: ____________

Section 8: FAMILY INTERESTS and INVOLVEMENT

Any special interests, hobbies or talents you have that you may wish to share with us eg sports, music: ______________________
________________________________________________________________________________________________________
Are there any religious or cultural events or festivals you celebrate as a family that we could also celebrate with the children at after
school care ? _____________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Are you a member of or part of any community group or organisation that we could build a community relationship with or participate
in projects to promote childrens learning of their community and environment? __________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________

OFFICE USE ONLY

The coordinator or member of management is to read through and ensure the enrolment record is completed in full.
Section 2: attached documents
Immunisation Statement
Asthma Action Plan yes / no
Anaphylaxis / Allergy Action Plan

yes / no

Medical Conditions Management Plan

yes / no

Section 3:
Emergency contacts completed
Section 4:
Payment received for registration
Section 8:
Individual child details completed in full
Signature of person confirming enrolment form _______________________________ Date ____________________

Warrawee Care Centre Enrolment Form 2014 (Confidential). Page 6

ABOUT MY CHILD : 2014 ENROLMENT

The information supplied will allow the staff to learn some current important details about your child. This information will be used to
provide learning opportunities and play experiences as part of our program to be able to cater for each child. We want to make your
childs time at the Centre as happy, safe and enjoyable as possible.
A separate page will need to be completed for each child.

Childs Name: _________________________________________

Is your child new to the Centre for 2014

yes / no

Background family information that you think we should be mindful of eg changes to home environments during the week, change in
family circumstances or parenting arrangements etc.
________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
_________________________________________________________________________________________________________
________________________________________________________________________________________________________

Please provide details about your child(rens) interests for example hobbies, sports, books, games, art and craft, music etc .
________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
_________________________________________________________________________________________________________

My childs strengths : ______________________________________________________________________________________

________________________________________________________________________________________________________

Family activities we like to share are: __________________________________________________________________________

________________________________________________________________________________________________________

Sporting groups or extra curricular activities my child participates in: __________________________________________________

_________________________________________________________________________________________________________

Behavioural concerns of your child or special needs at home or school:____________________________________________________

________________________________________________________________________________________________________

Social concerns you would like to share with staff about your child: ___________________________________________________
________________________________________________________________________________________________________

Does your child fear anything in particular? If yes, please provide details ______________________________________________
________________________________________________________________________________________________________

Strategies or ways to help your child settle when distressed, anxious or upset __________________________________________
________________________________________________________________________________________________________

Individual goals you would like us to work towards : _______________________________________________________________

Is there any additional information you would like to share with staff about your child ? ___________________________________
________________________________________________________________________________________________________
Warrawee Care Centre Enrolment Form 2014 (Confidential). Page 7

Warrawee Care Centre

Summary of Financial Arrangements for 2014

Fee
Registration
Charge
Daily Fee
Permanent

Amount
$50 per
family
BSC $10
ASC $17

Nature
Non-refundable fee payable by families to
have their child enrolled in the Centre.
This fee covers the normal daily
attendance of your child. An enrolled
child results in a fee commitment to the
end of that year.
If you wish to cancel your childs
attendance during the year, you must give
2 weeks written notice or pay the
equivalent amount in fees.

Daily Fee
Casual
(prebooked)

BSC $12
ASC $20

Non
Notification
Search Fee

$15

Late Fee for

Term Invoices

$100

Late Pick Up
Charge
Loss of
Placement

$25 per 15
mins or
part thereof

Must be prebooked in advance and paid

for at the time of use. Places are limited
due to licensed quota. Casual places
booked required 24hrs notice for
cancellation or fee will be charged.
This fee will be charged if staff have to
ring to account for your childs absence at
the Centre for after school care. Please
let the Centre know or record a message
in the diary if your child is going to be
absent.
Should you not pay the Term invoice by
the due date (Week 6), this fee will be
levied.
We would prefer not to charge any family
for this as if everyone pays on time equity
is maintained amongst all families.
PLEASE PAY ON TIME.
This fee will be charged after 6.30pm as
the Centre is closed and staff need to be
paid overtime to wait with your child until
you arrive.
Any families with outstanding fees at the
end of the term risk losing their place and
not being accepted for future care. This
decision will be made by Management .

Due Date
At time of enrolment.
Invoiced for each term (or part
thereof) that your child is
enrolled.
Term fees are invoiced in week
1 or 2 of each term and are
payable immediately in full but
no later than week 6 of that
term.
Payment can be by cheque,
cash, credit, eftpos or direct bank
deposit (for permanent families).
On booking or collection of child.
Payment can be by cheque,
cash, credit, eftpos
This will be added onto your
invoice to be paid at the end of
each term.

Immediately once the due date

has passed. A reminder notice
and/or updated term invoice will
be issued and must be paid
immediately.

This will be added to your invoice

to be paid immediately after.

Warrawee Care Centre Enrolment Form 2014 (Confidential). Page 8