Enrolment Form

1.

(First) CHILD DETAILS

SURNAME

Mother’s Name

____ ____

___________________________

CRN

_______________________

GIVEN NAME(S)

__________________________

Date of Birth CRN Mother’s place of employment

DATE OF BIRTH ___ / ___ / ______ YEAR LEVEL ___________________

(Second) CHILD DETAILS SURNAME

Mother’s contact phone number (H) ___ (B) (Mob) Email

____ ____ ____ ____ __

___________________________

CRN

_______________________

GIVEN NAME(S)

__________________________

Father’s Name Date of Birth Father’s place of employment

DATE OF BIRTH ___ / ___ / ______ YEAR LEVEL ___________________

(Third) CHILD DETAILS SURNAME

____ ____ ____ ____ __

___________________________

CRN

_______________________

GIVEN NAME(S)

Father’s contact phone number (H) ___ (B) (Mobile) Email

__

__________________________

DATE OF BIRTH ___ / ___ / ______

Who is responsible for the account?

__

____

5. STARTING DATE Before School Care

YEAR LEVEL ___________________

2.

After School Care

ADDRESS

6. EMERGENCY CONTACT DETAILS Post code:

(Other than primary caregiver/s) 1. Name

3. BOOKINGS Which days will the child attend?

_____

Relationship to child: [ Please tick]

PH: (H)

___

_____ (B)

(Mobile)

Before school care

After school care

_____ _____

Can this person collect your child from the program: Yes No 2 .Name_______________________________

Monday

Monday

Tuesday

Tuesday

Relationship to child:

Wednesday

Wednesday

PH: (H)

Thursday

Thursday

Friday

Friday

Casual

Casual

___

_____ (B)

(Mobile)

_____ _____

Can this person collect your child from the program:

*Any Changes of attendances please submit these in writing to OSHC.

4. PARENT DETAILS 8. MEDICAL DETAILS

Yes No

7. COLLECTION OF CHILDREN Are there special custody arrangements? Yes No If yes please provide a copy of all relevant documentation

Doctor’s Name

____

Doctor’s Contact Number

____

Doctor’s Address

__ ____

Medicare Number

____

Do you have Ambulance Subscription Yes/No

Before School Care: 6.45 – 8.45am After School Care:

13. PARENT/GUARDIAN DECLARATION

If yes – Ambulance Subscription Number ________________________________

I consent to the child/ren named above: 

Participating in the Before and or After School Care Program run by the Patterson Lakes Primary School Council;



Being transported from their school to the location where the Program is conducted from time to time;



Participating in walks or excursions from time to time, which will take place away from the location where the program is conducted; and



Appearing in photos taken and displayed for the purposes of promoting the Program

Relevant Medical History Does your child have special needs? e.g ADHD, wheelchair access

__ __ __

Please list all allergies, disabilities, asthma, and illnesses ___ ___ ___ Is your child on medication? If Yes give details

__

Yes/No ________

9. COUNTRY OF BIRTH Primary Language ______________________ Other Language/s ______________________ Requires Interpreter? Yes No To ensure priority of access according to Commonwealth Government requirements, please indicate which applies to your care requirements. 

Special circumstances



Work or Study related



Parent/Child disability



Respite

3.30 – 6.15pm

10. FEES

I agree that neither the Patterson Lakes Primary School Council nor its employees, or the Department of Education and Training and its employees will be liable for any loss of or damage to property or for any personal injury whosoever caused or of whatsoever nature which may be sustained by the child/ren named above whilst participating in the program or in any activities in connection with the program. Where it is impracticable to communicate with me, I authorise the person in charge of the Program from time to time to obtain all medical assistance and pass on relevant medical information as may be deemed necessary for the child/ren, and I agree to meet any expenses incurred in respect of such medical assistance. I agree that I have received and read the parent handbook and agree to the terms and conditions that are included in the handbook. I agree to pay all fees for participation in the program. I acknowledge that the program concludes at 6.15 pm. In the event that the child/ren is/are collected after this time, I agree to pay the late fee which is applicable for every 15 minutes, or part thereof, after 6.15 pm.” Signature of Parent/Guardian:

Date: ___/___/___

OFFICE USE ONLY Date enrolment form received

CHILD CARE BENEFITS [CCMS] To apply phone the FAO (Family Assistance Office) on 136150 or center link on 136150. Please quote CRN: 407 279 616J

___/___/___

All details completed

yes / no

Places available 

Parent notified 

Waiting list

Parent notified 



Fees are calculated weekly and the discount is applied to your weekly account or in a lump sum quarterly. Supervisors Signature ____________________________

11. OPERATING HOURS