enrolment-form-fdc-jan-2013 by Windermere

Childrenâ&#x20AC;&#x2122;s Services Enrolment Form A copy of this form will be provided to your FDC Educator/s prior to care being accessed. 48 Webb Street, Narre Warren 3805 Telephone: 9705 3200 Facsimile: 97967650

Suite 7, 532 Hampton Street, Hampton 3188 Telephone: 9598 5097 Facsimile: 9598 9597

e-mail: placements@windermere.org.au

CONTACT DETAILS: Parent/Guardian (Recipient of Child Care Benefit)

First Name

Last Name

Home Address: P/Code: Date of Birth: Email Address: Home Telephone No:

Mobile Telephone No:

Customer Reference No (CRN) (Phone Centrelink on 136 150 to be assessed for CCB) Employment Status (please circle) -

___ ___ ___/_

Full time / Part time / Student / Unemployed / Home duties

Place of Employment (where applicable)

Work Telephone:

Country of Birth:

Cultural Background:

Are you Aboriginal and/or Torres Strait Islander origin? (please tick) Yes, Aboriginal Spouse/Partner (where applicable)

Yes, Torres Strait Islander

Neither

First Name

Last Name

Home Address: P/Code: Date of Birth: Email Address: Home Telephone No:

Mobile Telephone No:

Employment Status (please circle) -

Full time / Part time / Student / Unemployed / Home duties

Place of Employment (where applicable)

Work Telephone:

Country of Birth:

Cultural Background:

Are you Aboriginal and/or Torres Strait Islander origin? (please tick) Yes, Aboriginal

Yes, Torres Strait Islander

Neither

Language/s spoken at Home: _____________________________________________________________ 1 of 11

CHANGE OF DETAILS INFORMATION: (Only to be completed when personal details from Pg 1 change)

Parent/Guardian ________________________________________________________________________________ (recipient of CCB)

Home Address _________________________________________________________________________________ ___________________________________________________________________ P/Code ____________________ Home Telephone No __________________________________ Mobile No __________________________________ Work Telephone No __________________________________ Email Address __________________________________________________________________________________

Partner _______________________________________________________________________________________ Home Telephone No __________________________________ Mobile No __________________________________ Work Telephone No ___________________________________

Parent/Guardian ________________________________________________________________________________ (recipient of CCB)

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INFORMATION ON CHILD REQUIRING CARE: Child’s Name:

First Name

Last Name

Home Address: P/Code: Date of Birth:

CRN:

Medicare No:

____ ___ ___ / _

Country of Birth:

___ ___ ___ / _

Cultural Background:

Male

Female

Intersex/unspecified

Is your child of Aboriginal and/or Torres Strait Islander origin? (please tick) Yes, Aboriginal

Yes, Torres Strait Islander

Neither

PLEASE WRITE YOUR EXPECTED DROP OFF AND PICK UP TIMES FOR THE DAYS YOU REQUIRE CARE IN THE SPACES BELOW:

MONDAY

TUESDAY

WEDNESDAY

THURSDAY

FRIDAY

SATURDAY

SUNDAY

Times:

Is transport to School or Kindergarten required for this child? (Please tick) Yes

Drop off

Pick Up

Is this child school aged?

Yes

If your child is attending School or Kindergarten, please list below: _______________________________________________________________________________________________ (please note if child attends Kindergarten a sessions form needs to be completed)

FAMILY ARRANGEMENTS Does the child live with: Other:

Both Parents

Mother

Father

Please explain:

ARE ANY OF YOUR OTHER CHILDREN ENROLLED IN ANOTHER CHILDCARE SERVICE? (BEFORE/AFTER SCHOOL CARE, HOLIDAY PROGRAMS ETC)

Yes

WHAT DATE WOULD YOU LIKE FAMILY DAY CARE TO BEGIN: 3 of 11

Number of Children _________

………/…………../ 20………..

COURT ORDERS RELATING TO THE CHILD: Are there any court orders relating to the powers, duties, responsibilities or authorities of any person in relation to the child or access to the child? No

go to the next section.

Yes

please complete the following:

1. Bring the original court order/s for staff to see and a copy to attach to this enrolment form; 2. If these orders: a) change the powers of a parent/guardian to: • • • • •

authorise the taking of the child outside the service by a staff member of the service; in the case of a family day care service, the taking of the child outside the family day care educator’s residence or family day care venue by a family day care educator, consent to the medical treatment of the child; request or permit the administration of medication to the child; collect the child from the service or family day care, AND/OR

b) give these powers to someone else, please describe these changes and provide the contact details of any person given these powers: ……………………………………………………………………………………………………………………………………………. ……………………………………………………………………………………………………………………………………………. ……………………………………………………………………………………………………………………………………………. ……………………………………………………………………………………………………………………………………………. …………………………………………………………………………………………………………………………………………….

*Is there other family information you feel the coordination unit/ educator should be aware of when providing care for your child? No Yes (please tick) If yes – Give details …………………………………………………………………………………………………………………………………... ………………………………………………………………………………………………………………………………………………………….. ………………………………………………………………………………………………………………………………………………………….. ………………………………………………………………………………………………………………………………………………………….. ………………………………………………………………………………………………………………………………………………………….. Special Needs:

*Is there anything else that the children’s service should know about the child? (eg excessive fears, favourite activities, attending other early childhood service or early intervention service, etc) ………………………………………………………………………………………………………………………………………………………….. ………………………………………………………………………………………………………………………………………………………….. ………………………………………………………………………………………………………………………………………………………….. …………………………………………………………………………………………………………………………………………………………..

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Details of people who you authorise to collect you child: (please supply a minimum of two) (Not including parent/guardian included on front page) Your consent is required for other people to collect the child from the children’s service on your behalf. In the table below please list the details of those people you have authorised to collect the child This list may be added to or changed throughout the year. In the event that the child is not collected from the children’s service and the parents or guardians cannot be contacted, this list will also be used to arrange someone to collect the child.

Name:

Address:

Telephone/s

(H)

(W)

(H)

(W)

(Mobile)

Relationship to child

Do you consent to this person being contacted in case of an emergency (please circle)

Yes

Do you consent to this person being contacted in case of an emergency (please circle)

Name:

Address:

Telephone/s

(H)

(W)

(H) (Mobile)

Relationship to child

of an emergency (please circle)

Yes

(W)

(Mobile)

Do you consent to this person being contacted in case

Yes

Do you consent to this person being contacted in case of

an emergency (please circle)

Yes

Declaration and consent to emergency medical treatment

(Print full name)

a person with lawful authority of the child referred to in this enrolment form, •

declare that the information in this enrolment form is true and correct and undertake to immediately inform the children’s service in the event of any change to this information;

•

agree to collect or make arrangements for the collection of the child referred to in this enrolment form if s/he becomes unwell at the service;

•

consent to the proprietor or in the case of a family day care, the family day care service to seek medical treatment for the child from a medical practitioner, hospital or ambulance service.

•

In a case of an emergency, you authorise your educator to seek verbal permission to administer medication from you or an emergency contact; OR verbal authorisation from a practitioner or paramedic if you, (the authorising) person cannot be reasonably contacted

Signature

Date

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Child’s health information

Name Doctor/Medical Service:

Telephone:

Address Doctor/Medical Service: Does your child have a child health record? If yes, please provide to the service for sighting. Child’s immunisation record: Is your child’s immunisation up to date?

Yes

(please tick)

If yes, please • attach a copy of the Immunisation Record from the Child Health Record book (blue cover) OR • attach a copy of the Immunisation Record printout from local government OR • attach the Child History Statement from the Australian Childhood Immunisation Register (http://www.medicareaustralia.gov.au or call 1800653809)

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

Position:

Does your child have any of the following?

Asthma No Yes ** (please tick) Diabetes No Yes ** Epilepsy No Yes ** Other No Yes If yes please provide details and management procedure to be followed. ( ** Management Plan, Risk Minimisation Plan and Communication Plans need to be supplied)

Does your child have any allergies or sensitivity?

Yes

(please tick)

If yes please provide details of any allergies and any management procedure to be followed with respect to the allergy.

Anaphylaxis Has your child been diagnosed at risk of anaphylaxis? ® Does your child have an auto injection device (eg EpiPen )? Has the anaphylaxis medical management plan been provided to the service? Has a risk management plan been completed by the service in consultation with you?

No No No No

Yes Yes Yes Yes

In the case of anaphylaxis you will by 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 is available at www.education.vic.gov.au/anaphylaxis Does your child have any other medical conditions that are relevant to the care of your child? No Yes (please tick) If yes please provide details of any medical condition and any management procedure to be followed with respect to the medical condition.

Does the child have any dietary restrictions? If yes, the following restrictions apply:

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Yes

(please tick)

PERMISSION FOR PHOTOGRAPHS Windermere Family Day Care Service occasionally advertises its services through local newspapers or flyers. We sometimes include with the article a photograph of an FDC Educator and the children they have in care. If you are happy for us to take photographs of your children whilst in Family Day Care please fill out the permission form below. I (Parent/Guardian) do hereby give permission for my child/ren to be photographed for the following purposes, please tick appropriate boxes. To be displayed in a FDC Educator’s home In Parent and FDC Educators newsletters. Also at our Playgroup venues and in the Coordination Unit reception area for new families to see. Windermere Family Day Care Service to take photographs of my child/ren for advertising and promotional purposes if and when required Please note: No photographs will be used without Parents/Guardians permission. I understand that photos will not be used for any purpose other than that stated here. Parent/Guardians signature: If you would like to withdraw permission at any time please notify your FDC Educator in writing as soon as possible

PERMISSION TO BATHE From time to time, it may be necessary for your FDC Educator to bathe a child. Are you happy for your chosen FDC Educator to bathe your child/ren if required? YES

Parent/Guardian’s signature: ________________________________________

We are required by DEEWR to send quarterly usage statements to families. If you choose not to receive this statement please tick this box You can view your usage on www.mychild.gov.au

How did you hear about Family Day Care? ……………………………………………………………………………………………………………………………………………..

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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 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 (refer to Appendix 1 for a summary). 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.

PRIVACY CONSENT FORM

I (client name) ……………..……………………………….…………………. OR if client is a child then consent must be given by parent/guardian/carer if the client is determined not to have capacity to give consent. I (print name) ………………………… as parent/guardian/carer for (client name)……………………. agree to health and personal information being collected, used and disclosed by Windermere or its health service providers and used in accordance with Windermere's Privacy Policy (available only 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, relevant Government Departments and others nominated on the Release of Information Form, 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 being 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 case files about me or until I withdraw consent in writing for disclosure of personal information. It is acknowledged that on occasions, after case closure or after consent is withdrawn that Windermere may be required by law to disclose my personal information.

Signature: ……………………………….. Client/Parent/Guardian

Print Name:

……………………………..

Date: .………………………………….

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

Signature:……………………………………………Name:……………………………………

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RELEASE OF INFORMATION FORM

SERVICE: ……………………………..………….…….…………………………. CLIENT NAME: ……………….………………………………..……….... WINDERMERE CLIENT DATABASE No: …….……………...

I ………………………………………………………… authorise the release of Client/Guardian name information between Windermere and the parties listed below: …………………………………..………………… …………………………………………………..… ……………………………………………………… ………………………………………………………

I ……………………………………………… do not authorise the release of information Client/Guardian name to: …………………..………………………………… …………………..…………………………………

Guardian/Client signature: ………………..………………………………

Guardian/Client name (print):…………………………………………….

Date : ……. /……. /…….

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FURTHER COMMUNICATION: Communication with our families is important to us, however we know your time is valuable. Would you like to hear (via phone) from a fieldworker about your child in care? YES

Best time to call? Contact phone number:

We are interested in input from our parents on how our service is run and are seeking parent representatives for our consultative group. This group meets 4 times per year on a Wednesday night. Are you interested in attending?

YES

Would you like further information in regards to the consultative group?

Any other comments / suggestions you wish to make?

What is your preferred method of providing feedback to the scheme about the quality of the service? Telephone Contact:

YES

Questionnaire:

YES

Other: (please state)___________________________________________________________________ Are you using/or have used any of Windermereâ&#x20AC;&#x2122;s other services If yes â&#x20AC;&#x201C; which services:

Using

YES

Have used

NO Using

Disability Services

Counselling

Victims Assistance Program

Family Support

Kids Becoming Champions

Housing support

Have used

Other Please state:

If no - are you interested in finding out any information about accessing these services? (Tick if interested) Disability Services

Counselling

Victims Assistance Program

Family Support

Housing support

Other

Please state:

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PARENTS’ AGREEMENT AND PERMISSION FORM

(please read fully)

• I/we give my permission to the person caring for my child/ren, or staff, that in case of accident or illness and I cannot be contacted, that medical advice and/or assistance be sought. I agree that all medical expenses will be my responsibility. • I/we agree to abide by the conditions as set out and undertake to pay the applicable fee as agreed to on the Fee Agreement Form and holding fee as negotiate with the FDC Educator. I acknowledge that payment for Family Day Care must be made on the day agreed and for the amount stated on the time sheet • I/we give permission for the child/ren to be taken on routine outings. • I understand FDC Educators may need to apply sunscreen and/or bandaids and I will provide information where this is a problem due to allergies (in such cases, parent/guardian will need to provide a safe alternative) • I approve of my child travelling in the FDC Educator’s vehicle and vehicles of the Coordination Unit provided that my child is securely fitted with an approved childcare restraint. • I/we agree that in the event of my child/ren contracting an infectious or contagious disease, he/she may be excluded from care for the period of time recommended by my doctor, or the Commissioner of Public Health. • I/we understand that the Coordination Unit will advise me of available FDC Educators and that the final choice of FDC Educator is mine. • I/we agree to deliver my children to the FDC Educator and sign my children in and out of care each day. • I/we agree to give the Family Day Care Service and my FDC Educator at least a week’s notice before terminating a placement with the FDC Educator, other than in an emergency situation. • I/we agree to be reliable and punctual in delivering and collecting my child/ren from the FDC Educator’s home. I will inform the FDC Educator if it is necessary to arrive earlier or later when delivering or collecting my child/ren (preferably on the day beforehand). • I/we have read the Windermere Family Day Care Service Information Booklet and I agree to meet these responsibilities and to meet the requirements of the program. • I/we understand that if care has not commenced within eight weeks of the completion of this form, this form will be destroyed by the Windermere Family Day Care Service Coordination Unit. •

I/we agree that Windermere Family Day Care Service pay my/our Child Care Benefit subsidy directly to the FDC Educator and deduct the administration levy from this subsidy prior to payment.

• I/we agree to advise the Family Day Care Service office and the children’s FDC Educator, if any of the information provided in this form changes. All information provided in this form will be handled in strict confidence.

PLEASE WRITE NAME: Applicant’s Signature Date:

/20

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