Enrolment Form

Child's Given Name/s

Family Name

Other names the Child is known by

Date of Birth

Gender

Male

Female

Non-Binary

Other (please specify below)

Please supply gender details (if "Other")

Address

Home Phone Number

Please bring a copy of your child's birth certificate

Bill fees to

Parent 1

Parent 2

Other (please give details below)

Bill fee details (if "Other")

Receive Statement of Account via email

Yes

No

Legal Guardian

Religion

Cultural Background

Primary Language

Healthcare card

Yes

No

Is your child of Aboriginal and/or Torres Strait Islander Origin?

Yes

No

Family Circumstances

Is there anyone who is prohibited from having contact with or collecting the child?

No

Yes (please give details below)

Family circumstances details (if you answered "yes" above)

Parent 1 Details

Parent 1 given name

Family name

Other names Parent 1 is known by

Address

Home Phone Number

Mobile Phone Number

Email Address

Parent 1 EMPLOYMENT DETAILS

Employer

Suburb

Work Phone Number

Hours

Occupation

Parent 2 Details

Parent 2 given name

Family name

Other names Parent 2 is known by

Address

Home Phone Number

Mobile Phone Number

Email

Parent 2 EMPLOYMENT DETAILS

Employer

Suburb

Work Phone Number

Hours

Occupation

Care Required

Days required

Start date required

Health/Medical details

Medicare Number

Private Health details

Does your child have a disability?

No

Yes (please provide details below)

Provide details (if you answered "yes" to disability above)

Is your child seeing a therapist?

No

Yes (please provide details below)

Provide details (if you answered "yes" to therapist above)

Does your child have a current NDIS approval number?

No

Yes (please provide details below)

NDIS Number

Family Doctor's name

Family Doctor's Phone Number

Family Doctor's address

Contact Doctor

Yes

No

Hospital (note which Hospital you would use in an Emergency)

Immunisation Details: Parents who wish to enrol their child are required to provide at the time of enrolment their child's immunisation status. This may be an AIR Immunisation History Statement or Form based on regulatory requirements and/or the state/territory's Public Health Act.

Please provide one of the following forms:

• An AIR Immunisation History Statement which shows that the child is up to date with their scheduled vaccinations or

• An AIR Immunisation History Form on which the immunisation provider has certified that the child is on a recognised catch up schedule (temporary for 6 months only) or

• An AIR Immunisation Medical Exemption Form which has been certified by a GP. The above can be obtained at your local Medicare Office or online at www.medicareaustralia.gov.au/online

If you answer ‘yes’ to any of the health-related questions, you must provide a supporting letter from your child’s medical practitioner.

Does your child have any allergies or food intolerances?

No

Yes (please provide details below)

Provide details (if you answered "yes" to allergies above)

Does your child have Anaphylaxis?

No

Yes

If yes, please provide a copy of your child’s ASCIA Action Plan.

Does your child have Asthma?

No

Yes

If yes, please provide a copy of your child’s Asthma Management Plan.

Does your child have an action plan?

No

Yes

If an action plan is in place, a Medical Conditions Risk Minimisation Plan and Communication Plan will also be required to be completed. Please speak to Catherine to complete the paperwork.

Please supply a copy of your Child's:

ACIR Immunisation History Statement, ACIR Contientious Objection Form, or ACIR Medical Contraindication Form

and

Birth certificate

How will you be providing these copies?

By email to admin@anzacvillagepreschool.com.au

Dropping in a copy to Anzac Village Preschool, 3 Chauvel Avenue WATTLE GROVE NSW 2173

Sending a copy by post to Anzac Village Preschool, 3 Chauvel Avenue WATTLE GROVE NSW 2173

You must select an option

Does your child have any additional needs?

No

Yes (please provide details below)

If yes, please provide a copy of a referral or assessment.

Provide details (if you answered "yes" to additional needs above)

Does your child have any current medical conditions?

No

Yes (please provide details below)

If yes, please specify and provide a copy of any management plans.

Provide details (if you answered "yes" to current medical conditions above)

Is your child currently on any prescribed medications?

No

Yes (please provide details below)

Provide details (if you answered "yes" to prescribed medications above)

Does your child have any dietary restrictions?

No

Yes (please provide details below)

Provide details (if you answered "yes" to dietary restrictions above)

Religious Requirements in case of Accident

Do you authorise Anzac Village Preschool Educators to take your child on outings/excursions when requested?

No

Yes

Please note: A separate consent form will be provided for any excursion after a risk assessment has been completed by Educators.

Is there any other information you wish us to know about your child?

Nominate at least two people to act on your behalf in the following circumstances:

Pick Up from care

Pick Up in an emergency

Authorisation of medication

Authorisation of excursions

Transport the child or arrange transportation of the child

Person 1

Additional contact 1 - Name

Relationship to child

Home phone

Mobile phone

Work phone

Home address

Work address

Daily pickup

Yes

No

Emergency pickup

Yes

No

Authorise medication

Yes

No

Authorise excursion

Yes

No

Authorise transport

Yes

No

Additional details?

Person 2

Additional contact 2 - Name

Relationship to child

Home phone

Mobile phone

Work phone

Home address

Work address

Daily pickup

Yes

No

Emergency pickup

Yes

No

Authorise medication

Yes

No

Authorise excursion

Yes

No

Authorise transport

Yes

No

Additional details?

Person 3

Additional contact 3 - Name

Relationship to child

Home phone

Mobile phone

Work phone

Home address

Work address

Daily pickup

Yes

No

Emergency pickup

Yes

No

Authorise medication

Yes

No

Authorise excursion

Yes

No

Authorise transport

Yes

No

Additional details?

Person 4

Additional contact 4 - Name

Relationship to child

Home phone

Work phone

Mobile phone

Home address

Work address

Daily pickup

Yes

No

Emergency pickup

Yes

No

Authorise medication

Yes

No

Authorise transport

Yes

No

Authorise excursion

Yes

No

Additional details?

Please contact us to add additional Authorised Nominees

In the Event of an emergency, illness or accident concerning my child, I consent to Anzac Village Preschool staff seeking on my behalf urgent medical, dental, hospital and ambulance services for my child and I consent to the carrying out of appropriate medical, dental or hospital treatment in the event that such action appears to be necessary because my child has been injured, or is ill, at the premises.

I accept any liability for medical, dental, hospital and ambulance that may be incurred.

I accept any liability or cost for the transportation of my child by an ambulance service;

I understand that the approved provider or nominated supervisor of the service will, as soon as practically possible, notify me or other persons so authorised by me of the accident or illness and the treatment or services arranged for my child.

I acknowledge and accept the above

Accepted by: Parent name

Date