enrolment-form

ECE0046

Early Childhood Education & Care Services Enrolment Form 2014 To enrol for the Early Learning Centre, please return the form to: Early Learning Centre 1A Holmes Street , Frankston VIC, 3199 (03) 9784 5300

To enrol for Family Day Care or In Home Care please return the form to: 48 Webb Street, Narre Warren, VIC, 3175 (03) 9705 3449

If you choose to email forms please send to enrolmentsECECS@windermere.org.au

Information relating to the service you are enrolling at: Which service are you enrolling at?

Early Learning Centre Family Day Care In Home Care Date this form was completed: _____________________________ The personal information collected by Windermere meets the legal and funding requirements of the National Education and Care Services Act and Regulations 2011, the Commonwealth Department of Education and the Victorian State Department of Early Childhood Education and Development.

The information will be solely used by Windermere in accordance with the organisations privacy policy and relevant privacy legislation.

Windermere may be required to disclose personal information from this document to the Department of Education and Early Childhood Development and the Department of Education.

The parent/guardian who has lawful authority for the child must complete this form. Please see a description of lawful authority below.

Lawful Authority: Parents: All parents have powers and responsibilities in relation to their children which can only be changed by a court order. The Education and Care Services National Regulations, 2011 refer to these powers and responsibilities as “lawful authority”. It is not affected by the relationship between the parents, such as whether or not they live together or are married. A court order, such as under the Family Law Act, may take away the authority of a parent to do something, or may give it to another person.

Guardians: A guardian of a child has lawful authority. A legal guardian is given lawful authority by a court order. The definition of “guardian” under the Education and Care Services National Act, 2010 also covers situations where a child does not live with his or her parents and there are no court orders. In these cases, the guardian is the person the child lives with who has day to day care and control of the child.

Page 1 of 12

ECE0046

When completing this form please use a black pen and print clearly.

Enrolment Details Part 1. Child’s Information Cultural Background

Given Name

Family Name

Is the child of Aboriginal and/or Torres Strait Islander origin? * (Please tick only one box)

No, not Aboriginal or Torres Strait Islander

Other Names

Yes, Aboriginal and Torres Strait Islander Home Address

Yes, Aboriginal Yes, Torres Strait Islander

Date of Birth

Has the family or child had a refugee experience Yes

Country Of Birth

Does your child have any dietary restrictions (not including allergies, this will be placed under medical conditions)?

Please provide details:

Gender (Please tick) Male

No

Female

Intersex/Unspecified

Language(s) spoken in the home:

Page 2 of 12

ECE0046

Part 2. Parent/Guardian information Parent/Guardian 1

Parent/Guardian 2

Given Name

Given Name

Family Name

Family Name

Home Address

Home Address

Postcode

Postcode

Postal Address (if different):

Postal Address (if different):

Email Address

Email Address

Phone Numbers

Phone Numbers

Home

Home

Work

Work

Mobile

Mobile

Date of Birth

Date of Birth

Country of Birth

Country of Birth

Ethnic Origin

Ethnic Origin

Languages Spoken

Languages Spoken

Gender (Please tick)

Gender (Please tick)

Male

Female

Intersex/Unspecified

Male

Occupation

Occupation

Relationship to child

Relationship to child

Page 3 of 12

Female

Intersex/Unspecified

ECE0046

Part 3. Emergency Contacts Please provide contact details of four people other than the child’s parents/guardians.

Emergency Contact 1

Emergency Contact 2

Name

Name

Home Address

Home Address

Phone Numbers

Phone Numbers

Home

Home

Work

Work

Mobile

Mobile

Relationship to the child

Relationship to the child

This person has the authority to collect the child

Yes

No

This person has the authority to collect the child

Yes

No

This person can be notified of any accident, injury, trauma or illness involving the child

Yes

No

This person can be notified of any accident, injury, trauma or illness involving the child

Yes

No

This person can authorise emergency medical or ambulance treatment for the child?

Yes

No

This person can authorise emergency medical or ambulance treatment for the child?

Yes

No

Emergency Contact 3

Emergency Contact 4

Name

Name

Home Address

Home Address

Phone Numbers

Phone Numbers

Home

Home

Work

Work

Mobile

Mobile

Relationship to the child

Relationship to the child

This person has the authority to collect the child

Yes

No

This person has the authority to collect the child

Yes

No

This person can be notified of any accident, injury, trauma or illness involving the child

Yes

No

This person can be notified of any accident, injury, trauma or illness involving the child

Yes

No

This person can authorise emergency medical or ambulance treatment for the child?

Yes

No

This person can authorise emergency medical or ambulance treatment for the child?

Yes

No

Page 4 of 12

ECE0046

Part 4. Hours/days required Preferred start date:

or Tuesday

Monday

Wednesday

Thursday

Friday

Saturday

Sunday

FDC/IHC Only

FDC/IHC Only

FDC/IHC Only

FDC/IHC Only

Arrival

Departure

Families in Family Day Care or In Home Care – If your child is accessing another service such as school, preschool or childcare - please indicate below the days and times you will need transport to and from these services.

Transport times and days

Tuesday

Monday

Wednesday

Thursday

Name of the School/Preschool/Childcare

Friday

Saturday

Sunday

Phone Number

Part 5. Childcare benefit Parent Customer Reference No. (Recipient of Child Care Benefit)

Do you receive a carer allowance on behalf of your child?

Yes

/

No

/

(CRN)

/

(CRN)

Name Does the child have a sibling listed on the family assessment notice who is attending another approved long day care, family day care, in home care, or specialised outside school hours care service?

Yes

Child Customer Reference No. /

No Name

Do you have a current Child Care Benefit Assessment Notice for this child?

Yes

Please note the child’s customer reference number is different to the parent customer reference number and can be obtained from Centrelink (Ph 136 150) or www.mychild.gov.au

No

Page 5 of 12

ECE0046

Part 6. Medical Conditions Children with medical conditions must, by law, have a medical action plan, risk minimisation and communication plans. All action plans must be signed by a medical practitioner prior to commencing with the service. More information on anaphylaxis requirements is at www.education.vic.gov.au/anaphylaxis.

Has your child ever had asthma? (Please tick) Yes

Has your child been diagnosed with Diabetes? (Please tick)

No

Yes

Has your children been diagnosed with Eczema? (Please tick)

Has your children been diagnosed at risk of anaphylaxis?

(Please tick)

Yes

No

Yes

No

No Does your child have any other Medical Conditions? (Please tick)

Has your child been diagnosed with an allergy? (Please tick) Yes

Yes

No

No

Has your children ever had an Epileptic Seizure? (Please tick) Yes

No

Does your child have any additional needs?

If yes, give details to assist us to meet their needs:

Services must obtain permission from parent/guardians to publicly display information about children’s medical conditions.

Displaying this reminds all staff of each child’s health and wellbeing needs.

I agree to have my child’s medical condition information displayed within the service.

Signature of Parent/Guardian

Date

Page 6 of 12

ECE0046

Part 7. Doctor Information Ambulance Cover

Name of Doctor/Medical Service

Yes

No

Address of Doctor/Medical Service

Subscription Number

Phone No

Maternal and Child (M&CH) Centre

Medicare No -Ref (Number next to name on card)

Part 8. Immunisation Information Name, date and signature of staff acknowledging receipt of health record and immunisation status

Has the child been immunised?

Yes

No

Name

Does your child have a child health record?

Yes

No

Position

A child health record is a record of a child’s health, development assessments and immunisations.

Date

You can provide information on your child’s immunisation by: t

attaching a copy of the Child History Statement from the Australian Childhood Immunisation Register (ACIR can be contacted on 1800 653 809) OR

t

attaching a copy of the immunisation record print out from local government OR

t

attaching immunisation exemption conscientious objection form

Part 9. Legal Orders Name of staff/educator sighting the original document

Are there any court orders, parenting orders or parenting plans?

Yes

No Time received

If yes, please provide the original document to be copied and attached to the enrolment form. If the orders change at any time please provide updated documentation.

Signature

Does Child Protection have current involvement with this child Yes

No

Page 7 of 12

Date received

ECE0046

Part 10. Priority of Access Windermere Early Childhood Education and Care Services make a commitment to provide quality education and care to the families both living and working within the community.

In allocating childcare places to families, we comply with the Department of Education & Family Assistance Office priority of access guidelines. This may mean an alteration to the care arrangements for some families who are using Windermere Early Years Education and Care Services for respite/social interaction purposes.

PRIORITY 1 – The Commonwealth Government regards children at risk of abuse or neglect as a priority for access to quality child care.

Families in crisis should also have support and assistance from child care services to the maximum extent possible. Children at risk are those who are on the “at risk register” at the Department of Education and Early Childhood Development.

PRIORITY 2 – A child/children of a single parent, or of parents who are both working/studying/training (as defined under section 14 of the Family Assistance Act) WORKING PARENTS – Currently employed LOOKING FOR WORK – Service needs confirmation of registration with Centre link STUDYING – Service needs confirmation of enrolment at an Educations Facility MATERNITY – During maternity leave if you choose to alter your care arrangements, there is no guarantee that your original position will be reinstated when you return to work. We will endeavour to accommodate your needs if/ when places become available.

PRIORITY 3 – Any other child.

RESPITE CARE – In times of high utilisation a non-working parent will be given a maximum of 1 day of care. If utilisation decreases additional days may be temporarily available to you.

I have read and understand the above procedure: Parent/Guardian Signature

Date

Page 8 of 12

ECE0046

Part 11. Privacy Policy Windermere Child & Family Services recognises the importance of privacy and understands concerns about the security of the personal information that is provided to us. We comply with the Health Privacy Principles (HPP’s) as contained in the State’s Health Records Act 2001 and the Information Privacy Principles (IPP’s) as contained in the Commonwealth’s Privacy Act 1988. Windermere also complies with the Public Records Act 1973 and the Freedom of Information Act 1982. All of our policies reflect rights to privacy, confidentiality and dignity in accordance with the above legislation and the various service standards that underpin service delivery.

I (Print Name)

as parent/guardian/carer for (child’s name)

agree personal information being collected, used and disclosed by Windermere is used in accordance with Windermere’s Privacy Policy (available on request) and relevant privacy legislation, and understand that disclosures may be necessary or advisable to monitor and evaluate service quality.

I also agree Windermere may disclose this information to other Windermere staff, relevant Service Providers and relevant government departments, for the purpose of providing services that are of benefit to me.

I understand that only information that is absolutely necessary for this purpose, or is required by law, will be disclosed.

I am also aware that statistical information (that will not identify me) may be collected and used to assist in improving this service or for research purposes, and I agree to this de-identified information being collected and shared.

This consent remains current while Windermere holds files about my child or until I withdraw consent in writing for disclosure of personal information. It is acknowledged that on occasions, after cease of care or after consent is withdrawn that Windermere may be required by law to disclose my personal information.

Parent/Guardian Signature: _____________________________

Date

Print Name

I have discussed the proposed services with the parent/guardian and am satisfied that the parent/guardian understands the proposed collection, uses and disclosures of personal information and has provided informed consent to these.

Educatore/Staff Signature: ______________________________

Date

Print Name

Page 9 of 12

ECE0046

Part 12. Permissions Photographs & Videos Photographs and videos are now classified as “Personal Information” under the Information Privacy Act 2000.

The purpose of this permission form is to: t

Comply with the privacy legislation in relation to photographs/videos taken at the early learning centre/family day care and in home childcare environment.

t

Enable staff/educators to take photographs/video of children as part of the program

t

Enable parents/guardians and staff/educators to take group photographs/video at special events such as birthdays or excursions.

t

Enable parents/guardians to take photographs/video of their children, which may include other children in the group.

t

Notify parents/guardians as to who will be permitted to take photographs/videos and where these are taken by the staff/educators how they will be used.

1. Photographs/videos/power point presentations taken by staff/educators, to be used with the service for programming use.

Staff/Educators will take photographs/video/power point presentations of children as part of the program which will include displaying these at the service or placing them in a book that may be borrowed from the service by the children attending. These may also be used for discussion at service parent meetings.

When the photographs/video are no longer being used as part of the program, displayed at the service or placed in a book for circulation, they will: t

Be given to the family of the child if the photograph/video is of their child and no other children.

t

Be stored securely at the service and displayed, for example, on anniversaries of the service

t

Destroyed.

2. Group photographs taken by parents/guardians or staff/educators.

Parents/guardians, as well as staff/educators, may take group photographs at special events such as birthdays or excursions while attending the service program or activity; which may also include other children in the group. Photographs taken by the staff/educators can be made available to parents/guardians.

While the service can nominate the use and disposal of photographs they organise, there is no control over those taken by parents/ guardians of children attending.

3. (Early Learning Centre Only) Photographs/video taken by photographer engaged to take annual photograghs/video of children.

Service may enlist an external professional photographer to take photos of the children during the year. This generally involves taking a group photo that is distributed to all families using the service at the time. There is no control over the distribution of photos taken by parents/guardians of children attending.

4. (Family Day Care/In Home Childcare Only) Photographs taken by staff/educators in the Education and Care Service home or playgroup venue.

Photographs/videos may be taken in the education and care service home or playgroup venue and displayed by Staff/educators or copies provided to parent/guardians 5. Photographs /videos for use in newspapers, websites (including the services own website)and other external publications.

Photographs/videos may be taken for use in newspapers, websites or other publications for marketing or promotional purposes.

NOTE: permission from parents/guardians will be obtained on each occasion prior to a child’s photograph being taken to appear in any newspaper/media or external publications.

Page 10 of 12

ECE0046

Parents/guardians need to note that the service management and staff have no control over the use of the photographs/video taken by parents/guardians.

Photographs and video permissions

Yes

I/we consent to photographs/videos and power point presentations taken by staff/educators to be used within the service for programming use I/we consent to photographs/videos being taken by staff/ educators/parents/ guardians of other children where my child may also be in the photo (Family Day Care / In Home Childcare Only) I/we consent to photographs/ videos being taken by staff/ educators in the education and care service home or playgroup venue and displayed (Early Learning Centre Only) I/we consent to Photographs/video taken by photographer engaged to take annual photographs/video of children I/we consent to photographs/videos being taken for use in newspaper, websites(including Windermere’s Website), marketing and other external publications

General permissions I/we have read and accept all the conditions of the application form, parent information book and Windermere’s Policy and Procedures I/we understand that the information in this enrolment form is true and correct and identifies all allergies and medical conditions known to me at this time.

I/we will agree to complete new enrolment form/s annually or in the event of any change to this information.

I/we agree to collect or make arrangements for the collection of the child referred to in this enrolment form if he/she becomes unwell at the service.

I /we consent to the staff/educators of the children’s service seeking, or where appropriate, administering necessary emergency, medical, dental, hospital or ambulance treatment as is reasonably necessary, in the event of any form of illness or accident occurring to the child as the service may determine in its absolute discretion. I/we will reimburse any necessary expenses incurred by the service I/we understand that my/our written permission will be sought for excursions outside the service.

I/we consent to my/our child/ren being bathed when attending to immediate hygiene needs.

I/we consent to for Staff/Educator/Program Coordinator’s to inspect your child’s hair for head lice as deemed necessary during the year?

I/we consent to the use of band aids on my/our child/ren if required.

Page 11 of 12

No

Parents Initials

ECE0046

Yes I/we give permission for staff/educators to apply sunscreen to my child as necessary during the time at the service.

I/we have read, fully understand and accept the conditions stated in the Fee/ Payment Procedure. I agree to pay fees in accordance with the conditions in this procedure.

Early Learning Centre Only I/we consent to the administration of paracetamol to my/our child/ren if required.

Family Day Care & In Home Childcare Only I/we agree to my/our child/ren going on outings outside the Family Day Care Educator’s home/ family home and understand that all reasonable care will be taken in the supervision of my child I/ we permit my/our child/ren to travel in a vehicle registered with the Family Day Care Service, with a registered Educator or Coordination Unit staff.

I would prefer to receive information/updates via:

Email

Mail

Parent/Guardian Signature: _____________________________

Date

Print Name

(For internal use only) Name, date and signature of staff acknowledging receipt of this enrolment record: Position: ___________________________________________

Date

Print Name

Page 12 of 12

No

Parents Initials