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    COPIES OF DDR collected Birth Certificate Immunisation Record Full Name Male Female Date of Birth address Postcode PRIMARY PARENT / GUARDIAN Full name address Date of Birth Work Phone Postcode Mobile Send all communication to this address. Authorisation Signed name Date INFORMATION RELEVANT TO THE SAFETY AND CARE OF CHILD Immunisations A copy of your child's Immunisation Record will be kept on file at Small Friends.

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    COPIES OF DDR collected Birth Certificate Immunisation Record Full Name Male Female Date of Birth address Postcode PRIMARY PARENT / GUARDIAN Full name address Date of Birth Work Phone Postcode Mobile Send all communication to this address. Authorisation Signed name Date INFORMATION RELEVANT TO THE SAFETY AND CARE OF CHILD Immunisations A copy of your child's Immunisation Record will be kept on file at Small Friends.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    49 views2 pages

    Enrolment Form PDF

    Uploaded by

    ourpatch
    COPIES OF DDR collected Birth Certificate Immunisation Record Full Name Male Female Date of Birth address Postcode PRIMARY PARENT / GUARDIAN Full name address Date of Birth Work Phone Postcode Mobile Send all communication to this address. Authorisation Signed name Date INFORMATION RELEVANT TO THE SAFETY AND CARE OF CHILD Immunisations A copy of your child's Immunisation Record will be kept on file at Small Friends.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    of 2

    ENROLMENT

    Date of Enrolment
    Sessions Requested

    Monday

    AM

    PM

    FD

    Tuesday

    AM

    PM

    FD

    Wednesday

    AM

    PM

    FD

    Thursday

    AM

    PM

    FD

    Friday

    AM

    PM

    FD

    Office only

    Returning Family
    Record

    CHILD

    Notes

    COPIES OF

    DDR collected

    Birth Certificate

    Immunisation Record

    Full Name

    Male

    Female

    CRN

    Date of Birth

    Address

    Postcode

    PRIMARY PARENT/GUARDIAN
    Full Name
    Address

    As above

    Home Phone

    CRN

    Date of Birth

    Work Phone

    Postcode

    Mobile

    Send all communication to this address.

    Email
    Place of Employment

    SECONDARY PARENT/GUARDIAN
    Full name
    Address

    CRN

    Date of Birth

    As above

    Home Phone

    Work Phone

    Postcode

    Mobile

    Send all communication to this address.

    Email
    Place of Employment

    AUTHORISED PERSON FOR DROP OFF COLLECTION EMERGENCY CONTACT

    Full Name

    Drop off

    Collect

    Address
    Home Phone
    Relationship to Child

    Emergency Contact
    Postcode

    Work Phone

    Grandparent

    Aunt/Uncle

    Mobile

    Friend

    Sister /Brother

    Other :

    AUTHORISED PERSON FOR DROP OFF COLLECTION EMERGENCY CONTACT

    Full Name

    Collect

    Drop off

    Address

    Postcode

    Home Phone
    Relationship to Child

    Emergency Contact

    Work Phone

    Grandparent

    Aunt/Uncle

    Mobile

    Sister /Brother

    Friend

    Other :

    AUTHORISED PERSON FOR DROP OFF COLLECTION EMERGENCY CONTACT

    Full Name

    Drop off

    Collect

    Address
    Home Phone
    Relationship to Child

    Emergency Contact
    Postcode

    Work Phone

    Grandparent

    Aunt/Uncle

    Mobile

    Sister /Brother

    Friend

    Other :

    DETAILS OF GUARDIANSHIP AND CUSTODY INCLUDING TERMS OF ANY SPECIFIC CUSTODY OR ACCESS PROVISION

    MEDICAL INFORMATION
    Childs Doctor

    Medical Centre/Surgery

    Address

    Phone

    Medicare Number

    Health Insurance Fund


    I hereby give my permission to Small Friends to call medical advice in the case of an emergency and agree to
    ..pay any expenses incurred for medical treatment and transport.

    Authorisation
    Signed

    Name

    Date

    INFORMATION RELEVANT TO THE SAFETY AND CARE OF CHILD


    Immunisations

    A copy of your childs immunisation record will be kept on file at Small Friends.

    Is your child fully immunised?

    Yes

    No

    Has your child been diagnosed with any of the following :

    Yes No
    Yes No

    German Measles
    Whopping Cough

    Measles
    Chicken Pox

    Allergies

    Yes

    No

    Notes

    Requires Regular Medication


    and/ or Medical Attention

    Yes

    No

    Notes

    Asthma or Recurrent Chest Infections

    Yes

    No

    Notes

    Seizures

    Yes

    No

    Notes

    Premature Baby

    Yes

    No

    Notes

    Skin Problems

    Yes

    No

    Notes

    Eyesight Problems

    Yes

    No

    Notes

    Other Chronic Health Conditions

    Yes

    No

    Notes

    Yes No
    Yes No

    Mumps

    Yes

    No

    Other :

    Previous Illnesses or Operations

    SPECIAL CARE NEEDS

    DIETARY NEEDS

    CULTURAL OR RELIGIOUS NEEDS

    OTHER INFORMATION
    Languages Spoken at Home
    Brothers and/or Sisters Names
    Other Relevant Information

    NOTES AND DECLARATION


    Illness

    A child cannot be accepted into our care with any illness, which may in any way be transferred to others.

    Media Permission

    You will need to inform us in writing if you do not wish for Small Friends to publish photos or videos of your child.

    Incursions and Outings


    ..

    We encourage members of the community to visit us for incursions, linking in with our programed themes.
    When an external outing is planned you will need to attend with your child.

    Non Payment of Account If payments fall behind by 1 week you will have until the following charge day to pay the account in full. If monies
    are still outstanding after 3 weeks your childs enrolment will cease, and debt collection procedures will be put in place by Small Friends.

    Signed by Parent or Guardian

    Date

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