ECE0046
Early Childhood Education & Care Services Enrolment Form 2016 To enrol for Family Day Care or In Home Care please return the form to: 18 Golden Green Street, Pakenham, VIC, 3810 1300 946 337
To enrol for the Early Learning Centre, please return the form to: Early Learning Centre 1A Holmes Street , Frankston VIC, 3199 (03) 9784 5300
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 organisation’s privacy policy and privacy statement/consent form. Windermere may be required to disclose personal information from this document to the Department of Social Services and the Department of Education and Training. 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.
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ECE0046
When completing this form please use a black pen and print clearly.
Enrolment Details Part 1. Child’s Information Given Name
Which ethnic group do you associate yourself with?
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
Preferred language for communication
Do you require the services of an interpreter? (Please tick) Yes
No
Please note we cannot guarantee an interpreter but will try to meet your request.
Family Day Care (FDC) educators and their partners are not entitled to receive child care payments for their own child's session of FDC if, on that same day, the FDC educator provides FDC for an approved FDC service, unless specified circumstances apply. If you are unsure if this applies to you or you want to tell us of your specified circumstances please speak to our Family Engagement and Participation Officer Are you an FDC educator? (Please tick) Yes
No
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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
Preferred language for communication
Preferred language for communication
Gender (Please tick)
Gender (Please tick)
Male
Female
Intersex/Unspecified
Male
Occupation
Occupation
Relationship to child
Relationship to child
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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
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ECE0046
Part 4. Hours/days required Agreed start date:
Educator Selected: Monday
Tuesday
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.
Monday
Tuesday
Wednesday
Thursday
Friday
Transport times and days Name of the School/Preschool/Childcare
Saturday
Sunday
FDC/IHC Only
FDC/IHC Only
Phone Number
Part 5. Childcare benefit Do you receive a carer allowance on behalf of your child? Yes
Parent Customer Reference No. (Recipient of Child Care Benefit) /
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
Child Care Benefit (CCB) is a payment made by the Commonwealth Government to assist families with the coast of quality care. To register for CCB you need to contact the Department of Human Services office on 136 150.
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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 been diagnosed with Eczema? (Please tick)
Has your child ever had asthma? (Please tick) Yes
Yes
No
Has your child been diagnosed at risk of anaphylaxis?
Does your child have any other Medical Conditions? (Please tick)
(Please tick)
Yes
No
Yes
No
No
If you have ticked yes please provide us with information of the medical condition below: Has your child been diagnosed with an allergy? (Please tick) Yes
No
Has your child ever had an Epileptic Seizure? (Please tick) Yes
No
Has your child been diagnosed with Diabetes? (Please tick) Yes
If you would like to read Windermere’s policy on medical conditions please let us know when you return this form.
No
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.
Does your child have any additional needs? If yes, give details to assist us to meet their needs:
I agree to have my child’s medical condition information displayed within the service. Signature of Parent/Guardian
Date
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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 Has the child been immunised? Yes
Name, date and signature of staff acknowledging receipt of health record and immunisation status
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: •
attaching a copy of the Child History Statement from the Australian Childhood Immunisation Register (ACIR can be contacted on 1800 653 809) OR
•
attaching a copy of the immunisation record print out from local government OR
•
attaching immunisation exemption conscientious objection form
Part 9. Legal Orders Are there any court orders, parenting orders or parenting plans? Yes
Name of staff/educator sighting the original document
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
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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 & Training and Department of Human Services 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 & Training . 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
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ECE0046
Part 11. Privacy Statement/Consent Windermere will • collect, use and store your personal information, including health information, in order to provide services to you and/or your family • use your email address (where provided) to send you information that may be of interest to you as identified by your worker. Every communication will provide you with an opportunity to opt out. You can also opt out by contacting your worker or by emailing us at info@ windermere.org.au • not use your personal information for any other purpose without your prior consent or allowed or required by law • comply with the Privacy Act 1988 (Cwlth), Privacy and Data Protection Act 2014 (VIC), as amended from time to time and the Health Records Act 2001 (Vic) • ensure that all personal information obtained about you will be appropriately collected, used, disclosed and transferred and will be stored safely and protected against loss, unauthorised access, use, modification or disclosure and any other misuse; and • in accordance with its privacy policy and the relevant privacy legislation, not disclose your personal information to others without your consent (see Release of Information form) You have a right to request access to your client record containing your personal information and may make a request to correct/update personal information at any time. Any request to access or update your client record must be made in writing to the Privacy Officer. When releasing information to others, Windermere will only share information that is necessary in order to provide the services that are of benefit to you, or as otherwise required by law.
Parent/Guardian Consent I (client name) consent to Windermere collecting and using information it collects from me in accordance with the above statements. Parent/Guardian Name (print)
Authorised Representative Name (print)
Parent/Guardian Signature
Relationship (e.g. Legal Guardian)
OR Date
Authorised Representative Signature Date
I have discussed the proposed services with the client and/or authorised representative and am satisfied that the client and/or authorised representative understands the proposed collection, use and disclosure of personal information. Educator’s Name (print)
Date
Educator’s Signature
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ECE0046
Part 12. Permissions Audio, Video and Still Images Audio, video and still images are now classified as “Personal Information” under the Information Privacy Act 2000. The purpose of this permission form is to: •
Comply with the privacy legislation in relation to audio, video and still images taken at the early learning centre/family day care and in home childcare environment.
•
Enable staff/educators to take audio, video and still images of children as part of the program
•
Enable parents/guardians and staff/educators to take group audio, video and still images at special events such as birthdays or excursions.
•
Enable parents/guardians to take audio, video and still images of their children, which may include other children in the group.
•
Notify parents/guardians as to who will be permitted to take audio, video and still images and where these are taken by the staff/educators how they will be used.
1. Audio, video and still images taken by staff/educators, to be used with the service for programming use. Staff/Educators will take audio, video and still images 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 audio, video and still images are no longer being used as part of the program, displayed at the service or placed in a book for circulation, they will: •
Be given to the family of the child if the audio, video and still images is of their child and no other children.
•
Be stored securely at the service and displayed, for example, on anniversaries of the service
•
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) Audio, video and still images taken by photographer engaged to take annual audio, video and still images 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. Audio, video and still images 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. Audio, video and still images for use in newspapers, websites (including the services own website)and other external publications. Audio, video and still images 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. 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. Permissions are for a 12 month period only.
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Audio, Video and Still Images permissions
Yes
I/we consent to audio, video and still images and power point presentations taken by staff/educators to be used within the service for programming use I/we consent to audio, video and still images 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 audio, video and still images 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 audio, video and still images taken by photographer engaged to take annual photographs/video of children I/we consent to audio, video and still images 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.
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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:
Parent/Guardian Signature: _____________________________
Print Name
Date
(For internal use only) Name, date and signature of staff acknowledging receipt of this enrolment record: Position: ___________________________________________
Print Name
Date
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No
Parents Initials