Year Round Care Online Enrolment Form This form is to be completed BEFORE your child/ren can attend Year Round Care. The information provided by you will be treated as strictly confidential and will not be used for any other purpose. Parents are required to provide Customer Reference Numbers (CRN) for yourself and your child/ren. Child/ren Enrolment Details Given Name(s)* - required Family Name* - required Address* - required Suburb / Postcode* - required Child's CRN* - required Date of Birth* - required Gender* - required Please Select Male Female Other Child's School* - required Nationality* - required Language/s Spoken* - required Aboriginal/Torres Strait Islander Religion* - required Medicare Number* - required Card Reference Number* - required Parent / Guardian 1 - Information Title Select Mr Mrs Miss Ms Sir Dr Full Name* - required Street Address* - required Suburb / Postcode* - required Phone Number* - required Mobile Number Email Address* - required Employer Name Work Phone Number Date of Birth* - required Do you consent to Tamworth Regional Council updating their records with the information provided above?* - required Select Yes No Family CRN* - required Are there any family situations that we should be aware of?* - required Yes No Family Details Please provide details of situation eg. custody arrangements etc. Parent / Guardian 2 - Information Full Name* - required Street Address* - required Suburb / Postcode* - required Phone Number* - required Mobile Number Employer Name Work Phone Number Collection / Emergency Contacts Persons collecting children from the centre MUST be 16 years of age or over. Any person not on this form will be refused collection unless prior arrangements are made with educators. If custody orders apply, a copy must be kept on your child/ren's file. The Medical Consent nominee is authorised to consent to medical treatment, or to authorise administration of medication to the child/ren. These people may be asked to show identification. Contact's Full Name* - required Relationship to Child* - required Street Address Suburb / Postcode Phone Number* - required Authorised Contact Type* - required Emergency Authorised Collection Medical Consent Authorised to authorise an educator to take the child outside the education and care service premises Authorised to authorise the education and care service to transport the child or arrange transportation of the child Family Doctor Name of Treating Doctor Name of Surgery Address Phone Number Relevant Medical History Has the child/ren been diagnosed or at risk of anaphylaxis?* - required Yes No Anaphylaxis Risk If yes, provide details (include name of child/ren) Action Plan, Risk Minimisation and Communication Plan need to be completed prior to enrolment. Medical History Details Please tick all that apply and provide further information in the space provided below. Allergies eg. Bees, food, grass etc Behavioural Needs Asthma - Action Plan required Disability / Special Needs Diabetes Other - specific healthcare needs including a medical condition A Risk Minimisation Form may also need to be completed. Please see an educator for further information. Please provide further details Immunisation Please provide an up-to-date copy of your child/ren's immunisation record. This MUST be provided before your child/ren can attend Year Round Care. If you are unable to upload a copy of your child/ren's record to this form, please ensure a copy is provided to the centre prior to your child/ren commencing care. Immunisation history statements are available online using your myGov login. Click here to log in. Copies may be uploaded in JPG or PDF format and each file must be 10MB or smaller. Upload immunisation record from Blue Book (optional) Upload immunisation record from Blue Book (optional) Upload immunisation record from Blue Book (optional) Upload immunisation record from Blue Book (optional) Service Access Please specify the reason for child care Work related care Child/ren with special needs Non-work related care Special Considerations Does the child/ren have any cultural or religious requirements?* - required Yes No Cultural/Religious Requirements If yes, please provide details (include name of child/ren) Does the child/ren have any dietary requirements/restrictions?* - required Yes No Dietary Requirements If yes, please provide details (include name of child/ren) Does the child/ren have any additional needs which may require special assistance? Eg. Early intervention, speech therapy, paediatric services, family support etc* - required Yes No Additional Needs If yes, please provide details (include name of child/ren) Are there any court proceedings or parenting plans relating to powers of duty and responsibilities?* - required Yes No Powers of Duty and Responsibility If yes, please provide details (include name of child/ren) Service Requirements Commencement Date* - required Requirements* - required After School Care Before School Care Vacation Care Confirmation is required each term for Before School and After School Care. Vacation Care bookings are taken from Week 8 each term. Please select the days you require* - required Monday Tuesday Wednesday Thursday Friday General Information Please provide any further information you would like us to know about your family and/or child/ren eg. Child needs to do homework before play Do you have any special skills that you could bring to our service? eg. Coaching, sewing, handyman etc Consent 1. Seek medical attention: I hereby give my permission for the educators at Year Round Care to seek medical attention for the above child/ren in the event of an accident/emergency. I understand that if an Ambulance is required, it will be at my cost, not the centre's. I give permission for my child to be transported by Ambulance if necessary. This may include medical treatment for the child by registered medical practitioner, hospital or Ambulance. 1. Seek medical attention* - required Please Select Yes No 2. Administer basic aid: I give my permissions for the educators at Year Round Care to administer paracetamol, apply Stingose and bandaids for the above child/ren.A courtesy call will be made prior to administering Panadol. 2. Administer basic aid* - required Please Select Yes No 3. Publicity imagery: I give permission for my child/ren to be involved in any photography or video taken for publicity purposes at Year Round Care. 3. Publicity imagery* - required Please Select Yes No 4. Fees:I have read and agree to adhere to the Year Round Care Fee Schedule and agree to pay my fees on a regular basis. I agree to keep my fees below $200 per child. 4. Fees* - required Please Select Yes No 5. Exclusion Policy:I have read and understood the Exclusion PolicyI agree to keep my child excluded from the centre if presenting any of the illnesses stated in the exclusion policy 5. Exclusion Policy* - required Please Select Yes No 6. Policy Manual:I understand that there is a Policy Manual kept in the sign-in area of each centre for parents and educators to refer to.I agree to adhere to these policies or risk losing my child/ren's place in the centre. 6. Policy Manual* - required Please Select Yes No 7. Observation:I give permission for the service to observe my child for programming purposes, to ensure the program reflects their individual needs and interests. All information gathered is confidential. 7. Observation* - required Please Select Yes No 8. Collection: I give permission for educators to collect my child from the school bus when arriving to After School Care and if using Before School Care to be put on the school bus, or walked to and from St Joseph's School. 8. Collection* - required Please Select Yes No Declaration All parents wishing to enrol their child/ren at Year Round Care must read and understand the Dealing with Medical Conditions Policy (PDF 193KB). By checking this box I declare I have read and understood the Dealing with Medical Conditions policy.* - required Privacy Statement Any personal information you have supplied to or is collected by Tamworth Regional Council will only be stored and processed by Council for lawful purposes directly related to the functions and activities of Council. Any personal information supplied will only be disclosed to a third party for the purpose of performing a lawful function or activity and for no other purpose. Disclosure of personal information to a third party will be in accordance with Tamworth Regional Council's Privacy Management Plan (PDF 331.7KB). Mandatory field(s) marked with *