Long Day Care Enrolment
Download the full application (PDF): Covenant ELC Long Day Care Enrolment Form
Covenant Christian School
Long Day Care Enrolment – All ages
Before & After School Care, Vacation Care
(Sherpa Kids Franchise)
CHILD INFORMATION (Please give names and details EXACTLY as registered with Centrelink records)
Family Name: First name(s):
Date of Birth: Age: Gender: M / F
Child CRN: School/Year Level:
Residential Address:
Suburb: Post Code:
Postal Address (if same write AS ABOVE):
Cultural Background: Aboriginal/Torres Strait Islander: Y / N
Country of Birth: Language(s) spoken at home:
ATTENDANCE REQUIREMENTS Preferred start date of permanent booking: ______
Please tick if you require Casual Care or Permanent Care (If permanent booking, please also tick which days below)
| Session | Monday | Tuesday | Wednesday | Thursday | Friday | All |
| Before School Care | ||||||
| After School Care |
PARENT/GUARDIAN INFORMATION – ACCOUNT HOLDER
(Please give full name and details EXACTLY as registered with Centrelink records)
Title: Family Name: First Name:
Date of Birth: Relationship to Child: Parent CRN:
Residential Address:
Suburb: Post Code:
Postal Address (if same write AS ABOVE):
Home Phone: Mobile Phone: Email:
Are you a single supporting parent/guardian: Y / N Are you working/studying: Y /N
If yes, Employer/Study Institution Name:
Employer/Study Institution Address: Phone:_________________________
Cultural Background: Country of Birth: Languages(s) spoken at home:
Do you receive JET/JFA Assistance? Y / N (if yes, please attached supporting documentation)
Do you have child(ren) enrolled at this service? Y / N Names:
Do you have child(ren) enrolled at another service? Y / N
Commonwealth Government Priority of Access Guidelines – Priorities A priority must be ticked which relates to your child:
- First Priority: a child at risk of serious abuse or neglect
- Second Priority: a child of a single parent who satisfies, or of parents who both satisfy, the work/training/study test under Section 14 of
- the ‘A New Tax System (Family Assistance) Act 1999’
- Third Priority: any other child (higher priority children may take a child’s place and 14 days notice will be provided for the child to vacate)
- Categories Please tick the category which relates to your child or tick None Below
- Children in Aboriginal and Torres Strait Islander families Children in families which include a disabled person
- Children in families from a non-English speaking background Children in socially isolated families
- Children of single parents
- Children in families which include an individual whose adjusted taxable income does not exceed the lower income threshold of $43,727, or whose partner are on income support
PARENT/GUARDIAN INFORMATION (Please give full name)
Title: Family Name: ___
First Name: ___
Date of Birth: Relationship to Child: Parent CRN: ___
Residential Address: ___
Suburb: Post Code: ___
Postal Address (if same write AS ABOVE): _________________
Suburb: Post Code: ___
Home Phone: Mobile Phone: ___
Email: ___
Cultural Background: Aboriginal/Torres Strait Islander: Y / N ___
Country of Birth: Language(s) spoken at home: __________
Are you working/studying: Y / N If yes, Employer/Study Institution Name: __________
Employer/Study Institution Address: Phone:________________________________________
EMERGENCY CONTACTS / AUTHORISED NOMINEES I consent for the following contacts, to collect my child from service including in the event of any incident, injury, trauma & Illness and to act as an Authorised Nominee consent to medical treatment of the child or to authorise the administration of medication to the child and to authorise an educator to take my child outside the service premises. (You must nominate at least one person other than parent/guardian aged over 18 years of age)
Contact 1 Title: Family Name: First Name: ___
Relationship to Child: Tel: Mob: ___
Address: ____
Contact 2 Title: Family Name: First Name: ___
Relationship to Child: Tel: Mob: ___
Address: ___
N.B. We may not release your child to an unlisted person without prior written notification. If any person not listed and not known to the Sherpa Kids staff, should attempt to collect your child from the service, permission will be refused.
AUTHORISATIONS I consent to the above named persons being able to authorise the approved provider, nominated supervisor or an educator to seek-
- medical treatment from a registered medical practitioner, hospital or ambulance service; and
- transportation of the child by ambulance service; and
- to authorise the education and care service to take my child on regular outings.
Name: Signature: Date:
With whom does the child mostly reside? ______________________
Is this child involved in court orders, parenting plans or orders? Yes No
If yes, please provide current and any changes to court documents at all times to enable enforcement. Please list below any other specific instructions or information you can provide that would be helpful and assist us in the care of your child.
____________
MEDICAL DETAILS & OTHER INFORMATION
Child’s Doctor: Address: ____________Phone: ________ _________
Health Fund Name: Health Fund Number: ___
Ambulance Membership No: Medicare Number: ___
|
Does your child have any of the following:
A.D.D. / A.D.H.D Epilepsy
Allergies (see box below) Haemophilia
Asthma Heart problems
Diabetes Anaphylaxis
Physical needs Behavioural needs
Educational needs Any other special needs
| Is your child on any medication? (Please complete a Medical Information & Authorisation Form) | Yes No | |
| Has your child been immunised? (Please provide immunisation record or Child History Statement from the Australia Childhood Immunisation Register prior to commencement at Sherpa Kids) | Yes No | |
| Does your child wear? | Prescriptions Glasses Hearing Aid | |
| Does your child have any of the following allergies? Please indicate severity e.g. High, Moderate, Low or Not Applicable | ||||
| 1. Bee Sting | High | Moderate | Low | N/A |
| Medication or Action to be taken: | N/A | |||
| 2. Food Allergy | High | Moderate | Low | N/A |
| Names of food/s & action to be taken | N/A | |||
| 3. Allergy to Medication Please name medication & action to be taken: | N/A | |||
| 4. Other Allergies Please describe & action to be taken (inc bandaids, latex etc) | N/A | |||
| Please provide information on any other dietary, cultural or religious considerations or special instructions regarding the health and well-being of your child (e.g. excessive fears) | N/A | |||
Child’s Interests: (Please tick below)
Art/Craft Music Drama Sports Structured Games
Cooking Technology Construction Reading Board Games
Please provide any other information about child’s interests/hobbies:
Please read and sign the following statements, ticking Yes/No where indicated:
- I hereby give permission to the staff of the above Sherpa Kids program to administer medically prescribed medication to my child and I will sign a Medical information & Authorisation form. I understand that the staff will record each administration of medication. Yes No
- I acknowledge that all care will be taken and will not hold Sherpa Kids responsible. I also understand my child cannot attend Sherpa Kids if suffering from an infectious or communicable disease that has been identified by the Department of Health.
- I hereby notify Sherpa Kids that my child carries medication with them and will self-medicate. I understand I will provide a letter/plan from a doctor to support this and I will sign a Medical information & Authorisation from. Yes No
- I hereby give my permission for the Sherpa Kids staff to treat my child if a minor accident occurs. In the case of a more urgent matter I understand an ambulance will be called first then I will be notified and agree to meet any expenses incurred.
- I understand the provider of the Sherpa Kids service is not liable for any personal injury, loss or damage to personal property due to any cause whatsoever unless there is proven negligence by the provider or employee.
- I understand Sherpa Kids staff have no responsibility to my child until I or an authorised person has signed my child in/out for each session of care.
- I hereby give Sherpa Kids permission to transport my child off a Sherpa Kids designated site of operation if and when required and that risk assessment plans will be undertaken for each occasion (e.g. evacuation, group trip)
- I acknowledge that photographs/video of my child or items of my child’s work completed at the Sherpa Kids program may be used at a later date for:
Local marketing and promotional purposes Yes No
National marketing and promotional purposes Yes No
(I hereby give my consent and no further permission will be required.) - I acknowledge that the information contained herein is confidential and pursuant to the Privacy Act, will only be strictly used by the Sherpa Kids team to effectively care for my child and not used or distributed for any other purposes. Representatives from appropriate Government Departments may view this information as part of the program assessment process.
- I authorise that my child’s school has permission to release all personal information about my child to Sherpa Kids.
- I hereby give my permission for the Sherpa Kids staff to apply sunscreen supplied by Sherpa Kids, if no other sunscreen is provided. I understand closed in shoes should be worn at each session of care and on excursion days. Yes No
- I hereby give permission for my child to watch G & PG rated movies and games. Yes No
Name: Signature: Date:
TERMS AND CONDITIONS
By signing below I, the Account holder, understand: (Please Tick)
- For a permanent booking, payment is required within 1 week of invoicing unless a weekly or fortnightly payment arrangement via bank account/credit card is in place.
- The rate charged, is dependent on whether it is a ‘permanent’ booking or not. When a child attends extra days, which are outside of the confirmed permanent booking, these will be charged at the casual rate. Late fees are charged for late pickups, as specified in the Centre Policies and Procedures. Full fees are charged if Centrelink details are not provided or correct details are not provided.
- I acknowledge that in order to keep my place at Sherpa Kids, I need to keep my account and payments up to date.
- Two weeks’ notice, in writing, must be provided if a child is to be withdrawn from care or there is a change required to the days of care, otherwise a two-week fee is payable based on the previous booking.
- No refunds are given for absences and all public holidays are charged at the applicable rate for bookings normally required that day. CCB is paid for up to 42 allowable absences for each child each year. After this full fees are charged for each absence unless there are exceptional circumstances that DHS approve.
- I understand Priority of Access guidelines apply and will update Sherpa Kids with any changes that may affect my priority rating
- Without prejudice to any other remedies, if at any time I am in breach of any obligation (including those relating to payment) Sherpa Kids may suspend or terminate the enrolment and is absolved of its other obligations under the terms and conditions. Sherpa Kids will not be liable to me for any loss or damage that I may suffer because Sherpa Kids has exercised its rights under this clause.
- Sherpa Kids can collect, retain and use any information about me for the purpose of assessing credit worthiness or marketing products and services and disclose information, whether collected by Sherpa Kids from myself directly or obtained by Sherpa Kids from any other source, to any other credit provider or any credit reporting agency for the purposes of providing or obtaining a credit reference, debt collection or notifying a default by myself.
- I have the right to request from Covenant Christian School ELC a copy of the information retained by Sherpa Kids for Long Day Care purposes and the right to request that Sherpa Kids correct any incorrect information about myself and my family held by Sherpa Kids
- I acknowledge by signing this form I understand and accept the Centre Policies and Procedures.
- I acknowledge all information I have provided on this form is true and correct and that I have provided Centrelink with this information. I am aware it is my responsibility to advise Sherpa Kids and Centrelink immediately of any change in the above information.
Name:
Signature: Date:
Office Use Only: Date Processed: Staff Initial:
All immunisation records, health records, management plans, court orders and other documentation have been sighted where applicable
Staff Initial:_______________