SURFCOAST VACATION CARE PROGRAM

ENROLMENT FORM – JULY 2011

Parent/Guardian Surname: Parent/Guardian CRN:__________________________

PLEASE NOTE: If you are a new family to the service a customer reference number (CRN) for the family and children are now
required before any bookings can be processed. To obtain CRN’s contact the Family Assistance Office on 136150.

Primary Parent First Name & Date of Birth:_______________________________________________________________________________________

Other Parents Name & Date of Birth:______________________________________________________________________________________________

Any Other Surname Used: Y or N______________________________________________________________ If yes please provide surname:

Home Address: _________________________________________________________________________________________________

__________________________________________________________________________________________________

Telephone: (H) (W) (M)_______________________

Name of another person to contact in case of emergency, if you are unable to be contacted:

Name: __________________________________________________________________________________________________

Telephone: (H) (W) (M)_______________________

CHILD/CHILDREN’S REGULAR SCHOOL: _________________________________________

CHILD/CHILDREN ATTENDING THE PROGRAM:

1. Name: ______________________________DOB:___________ CRN: Has your child been immunised?

YES/NO

2. Name: ________________________________DOB____________CRN: Has your child been immunised?

YES/NO

3. Name: ________________________________DOB:___________CRN: Has your child been immunised?

YES/NO

4. Name: ________________________________DOB____________CRN: Has your child been immunised?

YES/NO

Are your children from a non – English speaking background? YES NO Are they Aboriginal/Torres Strait/South Sea
Islanders? YES/NO

Do your children have any special requirements ie. religion, food, etc? YES/NO If yes please list in the space provided.

Please list any medical condition or allergies for each child enrolled in the vacation care program and advise staff on the child’s
first day.
A medication authorisation form must be completed if your child requires any medication whilst at the program.
If your child is diagnosed as at risk of Anaphylaxis you must provide a Anaphylaxis Action Plan signed by your doctor and an up
to date Epipen.
Your child will not be allowed to attend if the plan and Epipen are not brought to the program each day your child attends.

Name: ____________________ Medical Condition: Doctor: PH:________

Name: ____________________ Medical Condition: Doctor: PH:________

Name: ____________________ Medical Condition: Doctor: PH:_______

Name: ____________________ Medical Condition: Doctor: PH:________

PLEASE ANSWER THE FOLLOWING QUESTIONS

1. Are you using the program for work related reasons? Y/N
2. Will you be collecting your children each day? Y / N * If no please provide details of authorised person
over page.
3. Will you be claiming Child Care Benefit? Y/N
4. Have you registered this service with Centrelink? Y/N
5. Has Centrelink advised you of your CCB entitlement? Y/N
6. Have you received a copy of your assessment notice?
7. Will you be claiming CCB at another service during the program? Y / N * If yes please provide name of
service………………………………
8. Do you realise we have a 7 day cancellation policy. Tell parent - Y
9. Please ensure your child brings along their own named water bottle. Tell parent – Y
10. Please ensure your child brings enough food and drink to last all day. Tell parent – Y
11. Please ensure no food with nut products are brought into the program due to some children being at risk of anaphylaxis.
Tell parent - Y
12. All children must bring a broad brimmed hat. Tell parent – Y

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13. Spending money for excursion days is capped at $10.00. For 5-8 year olds it must be put into a named snap lock bag &
given to the Coordinator for safe keeping. In line with our ‘healthy food policy’ spending money is for souvenirs & healthy food
only. - Y
14. Are there any special access/custody arrangements? Y / N If yes please advise the service in writing.

15. Does a court order or other relevant restriction apply? Y / N If yes please provide the service with relevant legal paperwork
and details.
16. All forms MUST be signed prior to your child/children entering our program. Forms can not be signed on the first day.

PLEASE COMPLETE ENROLMENT RECORD ADDENDUM ON THE NEXT PAGE.

FURTHER INFORMATION ABOUT YOUR CHILDREN TO SHARE WITH OUR PROGRAM STAFF

Child’s names –

Are there any activities that your child particularly enjoys or has a special interest in?

Are there any other special considerations the staff will need to be aware of to ensure the
participation of your child in all activities?

What are the identified goals for your child’s inclusion into the school holiday program?

What is a calming activity for your child?

What is your child’s favourite activity to do at school?

Any further comments?

PRIVACY POLICY
The Surfcoast Shire considers that the responsible handling of personal information is a key aspect of democratic governance,
and is strongly committed to protecting an individual’s right to privacy. Council will comply with the information privacy
principles as set out in the Information Privacy Act 2000. Surfcoast Sport & Recreation Centre will only use the personal
information on this form for the purpose of statistics and child care benefit requirements. The information will not be disclosed
to any other party unless Council is required to do so by law. You can view and change the information by contacting the office
on 52614606.
DECLARATION
I the undersigned approve of the enrolment and agree to abide by the policies and procedures of the program and meet any
costs as advertised. I authorise the Coordinator in the event of any unforeseen accident or illness to obtain medical assistance
or an ambulance as required and agree to meet any expenses attached to such treatment. I give permission for my child/ren to
be taken on any excursions and outings as organised by the program and to watch G or PG rated movies/dvd’s. I will accept full
responsibility for my child’s belongings and any spending money whilst attending the program. I fully understand that if my
child continuously misbehaves, and after behaviour guidance procedures have been followed, I will be notified and my child
may be removed from the program. I agree to give the program 7 days notice for any absence of my child/ren and accept that
the full fees will be charged if less than 7 days notice is given. I acknowledge that my child/ren will not attend the program if
suffering from an infectious or contagious illness. In the event that my child is injured or becomes ill during the program,
either an authorised person or myself shall collect the child as soon as practical. I authorise leaders to apply sunscreen to my
child and to wear a hat provided by the program for use outdoors if necessary. I give consent to the staff to take photographs
or video footage of my child during activities in the program for the Commonwealth Government Quality Assurance
Accreditation and for other promotional use of the program.

Signed:__________________________________________Parent/Guardian

Dated:___________________________________________

AUTHORISATION TO COLLECT CHILDREN:

Name of persons:___________________________________________________________________________________________________________________

________________________________________________________________

Relationships: _________________________________Dates:_________________________________________________

Office Use Only: Date / / Amount Paid $ Date / / Amount Paid $

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 PLEASE ENSURE THAT ALL REQUIRED AREAS ARE SIGNED ON
THIS ENROLMENT FORM BEFORE THE PROGRAM COMMENCES.
IF NOT SIGNED WE CANNOT ACCEPT YOUR BOOKING.

SURFCOAST VACATION CARE PROGRAM BOOKINGS

DATES NAMES OF CHILDREN ATTENDING REGULAR BIG DAY OUT

PROGRAM PROGRAM
WEEK 1 (please tick) (please tick)

MON 4th

TUES 5th

WED 6th

THURS 7th

FRI 8th

SURFCOAST VACATION CARE PROGRAM BOOKINGS

DATES NAMES OF CHILDREN ATTENDING REGULAR BIG DAY OUT

PROGRAM PROGRAM
WEEK 2 (please tick) (please tick)

MON 11th

TUES 12th

WED 13th

THUR 14th

FRI 15th

Enrolment record addendum for children’s services

Children’s Names & Dates of birth - Name……………………………………………………………….. Date of

Birth…………………………………
Name………………………………………………………………. Date of
Birth…………………………………
Name………………………………………………………………. Date of
Birth…………………………………
Name………………………………………………………………. Date of
Birth…………………………………

A parent or guardian who has lawful authority in relation to the child must complete this form. A brief explanation of lawful
authority is found at the end of this form. Licensed children’s services may use this form to collect the child’s enrolment
information as required in regulations 31 to 35.

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Health Information

Does child/children have any special needs? Yes No

If yes, please provide name & details of any special needs and any management procedure to be followed with respect to the
special need.
……………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………..
Anaphylaxis

Has your child been diagnosed at risk of anaphylaxis? Yes No

Name of child___________________________________________________________
(only if you answered yes to above question)

Does your child have an auto injection device (eg EpiPen)? Yes No

Has the anaphylaxis medical management plan been provided

to the service? Yes No

Has a risk management plan been completed by the service in Yes No

consultation with you?

In the case of anaphylaxis you will be provided with a copy of the services anaphylaxis management policy.
You will be required to provide the service with an individual medical management plan for your child signed
by the medical practitioner who is treating your child. This will be attached to your child’s enrolment form.
More information can be found at www.education.vic.gov.au/anaphylaxis

Does your child/children have a child health record? Yes No

If yes, please provide to the service for sighting

Yes No

Child health records means a record that documents a child’s health and development assessments and
immunizations.

Name and position of person at the children’s service who has sighted the child’s health record.

Name________________________________________________Position______________________________________________

Confidentiality of enrolment records

The proprietor of the children’s service must ensure that information in the child’s enrolment record is not divulged to
another person unless necessary for the care or education of the child, to manage medical treatment of the child, where
expressly authorized by the parent or prescribed in the Children’s Services Regulations 2009 (regulation 35(1)(d-e)

I, ____________________________________________________(name) declare as the person with lawful authority of the child referred
to in this enrolment form that the information provided is true and correct and undertake to immediately inform the
children’s service in the event of any change to this information.

Parent’s signature________________________________________________Date____________________________

Lawful Authority

Parents
All parents have powers and responsibilities in relation to their children that can only be changed by a court order. The Children’s Services
Regulations 2009 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 have lived 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 also has lawful authority. A legal guardian is given lawful authority by a court order. The definition of ‘guardian’ under the
Children’s Services Act 1966 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.

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