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1 15 Sapium Rd, Southport, 4215 ph: e: Office Use Only: Class Required: Date of Commencement: ENROLMENT FORM 2017 Enrolled Formal Pending Date of Enrolment: PART 1 CHILD/FAMILY INFORMATION Child s Full Name:... Male Female Date of Birth:... Home Address:... Please provide proof of age e.g. birth certificate... Postcode:... Age on Commencement:... Child s CRN:... Child s Medicare No.: Indigenous Status: Aboriginal NOT Torres Strait Islander Torres Strait Island NOT Aboriginal (please tick) Aboriginal AND Torres Strait Islander NOT Aboriginal nor Torres Strait Islander DAYS OF ATTENDANCE (please circle): Monday Tuesday Wednesday Thursday Friday Guardian No.1:... Relationship to Child:... Guardian No.1 Date of Birth:... Guardian No.1 CRN:... Address: Telephone (H):... Mobile:... Workplace:... Telephone (W): Family Medicare No.:... Guardian No.2:... Relationship to Child:... Guardian No.2 Date of Birth:... Guardian No.2 CRN:... Address: Telephone (H):... Mobile:... Workplace:... Telephone (W): Family Medicare No.:... Note: (please read and indicate accordingly): Under Australian Human Services Guidelines, it must be noted the occupation of both parents. Please circle the category into which you fall. If one or both (1) Child at Risk parents are working, please indicate your place of employment above. **Please note that (2) Working (2) Working/Training/Studying can be on a part-time or full-time basis** (3) All other children Is your family eligible for Child Care Benefit and/or Child Care Rebate? (please tick) CCB CCR Which CRN do you prefer to use to claim CCB and/or CCR? (please tick) Guardian 1 Guardian 2 Who is liable for the cost of care and responsible for the payment of fees? (please tick) Guardian 1 Guardian 2 Please note: You must notify the Centre ASAP of any changes in circumstances which may affect your payments of CCB and/or CCR. For example: number of children in care, family separation, JET eligibility. The Centre cannot guarantee backdating of payments if you fail to inform us of any changes. SIBLINGS IN CHILDCARE (please supply documentation on enrolment): Name:... Centre:... Name:... Centre:... Name:... Centre:... Please note: If you have more than one child in care, you must notify the Centre ASAP and provide your multi child percentage rate to ensure that we can apply this to your fees. This includes families who have siblings that attend other child care providers services as well.

2 PART 2 ADDITIONAL & EMERGENCY INFORMATION EMERGENCY CONTACT PERSON/S (OTHER THAN PARENTS): Name:... Telephone:... Address: Name:... Telephone:... Address: Do you agree the above mentioned person/s has the authority to approve medical treatment or excursion permission? YES/NO AUTHORISED PERSON/S FOR DELIVERY & COLLECTION (OTHER THAN PARENTS): Name:... Telephone:... Address: Name:... Telephone:... Address: Are there any custodial arrangements, current Court Orders, Parenting or Parenting Plans which may affect your child? YES/NO (If YES, please provide documentation at time of enrolment.) Primary Language of Family:... Would you like our educators to communicate in your language? YES/NO Special Cultural or Religious Requirements:... Does your child have any other special needs (including any previous illness or injury) with which the knowledge will assist us in our care? YES/NO. If YES, please provide details... MEDICAL INFORMATION Does your child suffer from any allergies? YES/NO. If YES, please provide details Dietary Requirements: As BELC provides meals, please indicate whether your child has any dietary requirements, food allergy or food intolerance. (please also provide your medical practitioner, dietician or nutritionist s plan):.. If your child has a medical condition, we MUST have a management plan/anaphylaxis medical management plan? Copy provided: Yes/No Staff member signature for sighted:. Please provide a copy of your child s health record. Copy provided: Yes/No Staff member signature for sighted:. Has your child received all vaccinations relevant to his/her current age? Yes/No (Please provide Immunisation History Statement upon enrolment. Contact 13HEALTH or available from Polio Tetanus Whooping Cough Diptheria Hib Meningoccocal Other... Staff member signature for sighted:. Family Doctor:... Practice:... Address:... Telephone:......

3 EMERGENCIES I n t h e e v e n t o f a n a c c i d e n t o r i l l n e s s r e q u i r i n g e m e r g e n c y m e d i c a l t r e a t m e n t, t r e a t m e n t w i l l c o m m e n c e f i r s t, t h e n e v e r y e f f o r t w i l l b e m a d e t o c o n t a c t t h e p a r e n t s / c a r e r s a s s o o n a s p o s s i b l e. I n t h e s e c a s e s, i t w i l l b e n e c e s s a r y f o r a u t h o r i t y t o b e g i v e n f o r t h e t r e a t m e n t t o b e u n d e r t a k e n. T h i s i n c l u d e s t r a n s p o r t t o a n a p p r o p r i a t e f a c i l i t y b y c a r o r a m b u l a n c e. P a r e n t s a r e a s k e d t o c o m p l e t e a n d s i g n t h e f o l l o w i n g : - I _ a u t h o r i s e t h e s t a f f o f B e n o w a E a r l y L e a r n i n g C e n t r e t o s e e k e m e r g e n c y m e d i c a l t r e a t m e n t f o r m y c h i l d _ s h o u l d t h i s b e n e c e s s a r y. T h i s i n c l u d e s t r a n s p o r t t o t h e t r e a t m e n t c e n t r e ( w h e t h e r i t b e t h e d o c t o r s s u r g e r y o r h o s p i t a l ) b y c a r o r a m b u l a n c e i f n e c e s s a r y. F u r t h e r m o r e, I h a v e r e a d a n d a g r e e t o a b i d e b y c o n d i t i o n s o f u s e o f t h e C e n t r e a n d t o a c c e p t s u c h r e s p o n s i b i l i t y a s e n r o l m e n t a t t h e c e n t r e i m p o s e s. S i g n e d : _ Hospital I w o u l d l i k e m y c h i l d t a k e n t o : _ EMERGENCY CONSENT ST ATEMENT I _ ( p a r e n t / g u a r d i a n ) c o n s e n t t o e d u c a t o r s a t B e n o w a E a r l y L e a r n i n g C e n t r e a d m i n i s t e r i n g V e n t o l i n a n d / o r E p i p e n i n j e c t i o n f o r _ ( c h i l d s n a m e ) w h e n t h i s i s c o n s i d e r e d r e a s o n a b l y n e c e s s a r y i n a n e m e r g e n c y. S i g n e d : _ PANADOL A s s t a t e d i n t h e P a r e n t H a n d b o o k, I u n d e r s t a n d t h a t i n a n e m e r g e n c y s i t u a t i o n o n l y, P a n a d o l a s a t e m p e r a t u r e r e d u c i n g m e d i c a t i o n w i l l b e a d m i n i s t e r e d o n a o n c e o n l y b a s i s b y s t a f f o f t h e C e n t r e ; a n d t h e r e a f t e r I w i l l b e r e s p o n s i b l e f o r c o n s u l t i n g m y m e d i c a l p r a c t i t i o n e r. I h e r e b y g i v e m y p e r m i s s i o n f o r t h e a d m i n i s t r a t i o n o f t h e s i n g l e d o s e. S i g n e d : _ PART 3 SIGNATURES COMPLIANCE WITH HEALTH AND HYGIENE PRACTICES I c e r t i f y t h a t I h a v e r e a d t h e r e l e v a n t h e a l t h a n d h y g i e n e p o l i c i e s i n o p e r a t i o n a t B e n o w a E a r l y L e a r n i n g C e n t r e ( i n c l u d i n g t h o s e p e r t a i n i n g t o m e d i c a t i o n a n d c o n t a g i o u s i l l n e s s ) a n d t h a t I a g r e e t o a b i d e b y t h e s e p o l i c i e s. S i g n e d : _ PHOTOGRAPHS/WEBSITE I g i v e p e r m i s s i o n f o r B e n o w a E a r l y L e a r n i n g C e n t r e t o t a k e p h o t o g r a p h s o f m y c h i l d f o r t h e c h i l d s d e v e l o p m e n t b o o k, t o d i s p l a y i n m y c h i l d s c l a s s r o o m a n d h a l l w a y s o f t h e c e n t r e a n d t o a p p e a r o n t h e c e n t r e s w e b s i t e. S i g n e d : LOCAL OUTINGS I h e r e b y g i v e m y p e r m i s s i o n f o r t h e s t a f f o f B e n o w a E a r l y L e a r n i n g C e n t r e t o t a k e m y c h i l d o n l o c a l ( w a l k i n g o n l y ) o u t i n g s. T h i s p e r m i s s i o n i s a l s o t o i n c l u d e v i s i t s t o s h o w s o r f i r e d r i l l p r a c t i c e s t h a t o c c u r i n t h e c a r p a r k o f t h e C e n t r e, a n d s i b l i n g o r o t h e r v i s i t s b e t w e e n t h e B e n o w a E a r l y L e a r n i n g C e n t r e a n d B e n o w a E a r l y L e a r n i n g C e n t r e B a b i e s. ( P a r e n t s w i l l r e c e i v e a s e p a r a t e f o r m f o r e x c u r s i o n s n o t i n t h e l o c a l a r e a ). S i g n e d : _ AFTER SCHOOL CARE (need onl y be signed by Af t e r School Ca re Par e nts ) I r e c o g n i s e t h a t, w h i l s t e v e r y c a r e w i l l b e t a k e n i n p i c k i n g m y c h i l d u p f r o m B e l l e v u e P a r k S t a t e S c h o o l f o r a f t e r s c h o o l c a r e, o n o c c a s i o n s w h e n I h a v e f a i l e d t o n o t i f y B e n o w a E a r l y L e a r n i n g C e n t r e, t h a t m y c h i l d i s n o t a t s c h o o l, o r m y c h i l d h a s t a k e n i t u p o n t h e m s e l v e s t o m a k e a l t e r n a t i v e a f t e r s c h o o l a r r a n g e m e n t s, t h e y w i l l o n l y b e h e l d r e s p o n s i b l e f o r t h o s e c h i l d r e n w h o h a v e c o m e i n t o t h e i r c a r e ( a s r e p r e s e n t e d b y t h e a f t e r s c h o o l c a r e s i g n - o n s h e e t ). S i g n e d :

4 PAYMENT OF FEES ( F e e s a r e p a i d W E E K L Y v i a d i r e c t d e b i t w i t h E z i d e b i t. D e f a u l t o f a g r e e d p a y m e n t s f o r 2 c o n s e c u t i v e w e e k s w i l l r e s u l t i n your child s days being forfeited.) I c e r t i f y t h a t I h a v e r e a d t h e r e l e v a n t f e e p o l i c i e s i n o p e r a t i o n a t B e n o w a E a r l y L e a r n i n g C e n t r e a n d t h a t I a g r e e t o a b i d e b y t h e s e p o l i c i e s a n d t a k e r e s p o n s i b i l i t y f o r t h e p a y m e n t o f f e e s i n a g r e e m e n t w i t h t h e a f o r e m e n t i o n e d B E L C F e e P o l i c y. P r i n t N a m e : _ S i g n a t u r e : SIGNATURES _ G u a r d i a n N o. 1 G u a r d i a n N o. 2 D a t e We would like to welcome you to Benowa Early Learning Centre and we thank you for entrusting us to care for your child. We hope your child will enjoy many happy and treasured moments here and that your family s stay with us will be a long and happy one.

5 PRE COMMENCEMENT CHECKLIST Please ensure you have completed each section of the enrolment form and have included the following attachments: Copy of Child s Birth Certificiate.. Ezidebit Direct Debit Request Form. A current headshot photograph of child to be enrolled. Child s Health Record Child s Immunisation History Statement. Medical Management Plan, Anaphylaxis Medical Management Plan (if applicable) Dietician s or Nutritionist s Plan (if applicable) Custodial arrangements, current Court Orders, Parenting or Parenting Plans (if applicable).. Copy of your current Health Care Card (if applicable)... INFORMATION ABOUT YOUR FEES Fees at Benowa Early Learning Centre are paid WEEKLY via Ezidebit direct debit (default of agreed payments for 2 consecutive weeks will result in your child s days being forfeited). If you are eligible, we estimate your fees to include your Child Care Benefit in advance. You will only need to pay the gap in outstanding fees. IMPORTANT: Ensure that you have been in contact with the Dept of Human Services (formerly Family Assistance Office) before you start care. Ask to be assessed for Child Care Benefit (CCB) and choose the reduced fees payment option. Do this even if your income is too high for CCB so that you can get Child Care Rebate. Child Care Benefit (CCB) Helps with the cost of child care such as long, family or occasional day care, outside school hour care, vacation care, pre-school and kindergarten. Eligibility Basics use approved or registered child care be responsible for paying the child care fees have immunised your child Child Care Rebate (CCR) Covers 50% of out of pocket child care expenses, up to a maximum amount per child per year, in addition to any amount you may receive from Child Care Benefit and Jobs, Education and Training (JET) Child Care Fee Assistance. Eligibility basics you use a Child Care Benefit approved child care service you are eligible for Child Care Benefit for approved care, even if you earn too much to receive payment, and you and your partner meet the Work, Training, Study test or are exempt from it If you are eligible for the Child Care Rebate and choose to have the amount paid directly to the Centre, the amount is paid in arrears (i.e. in the week following attendance). For more information:

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9 To assist your child s educators, please complete the following Child Profile: Child s Name: D.O.B.: Gender: Parent s Name/s: Sibling s Name/s: Family s Cultural/Ethnic Heritage: Family s Special Customs or Traditions: Language/s Spoken at Home: If child has English as their second language, please list the following key words in your language. What interests, talents, cultural abilities do you have that may be relevant to our program? What interests does your child have? Food: Drink: Toilet: What has your child recently achieved? i.e. greets others, makes bed, etc. What would you like your child to achieve in the next 6 months? Does your child have any speech problems, hearing difficulties or behavioural problems? Special circumstances or considerations that we should know about: Does your child have any fears. i.e. storms, water, balloons? Yes/No Details: Yes/No Details: Does your child separate easily? Is your child toilet trained? Does your child have a comforter? i.e. a blanket or special toy? Any other comments:

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