CONFIDENTIAL ENROLMENT FORM...This form must be completed by a parent or guardian who has parental responsibility in rela on to the child. A brief explana on of ‘parental responsibility’

Kid-Z Educational Resources PAGE 1UPDATED TO NATIONAL QUALITY FRAMEWORK AT TIME OF PRINTING IN ACCORDANCE WITH REGULATION 160 162. WWW.BELLBIRDKIDZ.COM.AU RE ORDER CODE 129703 © COPYRIGHT 2016. REVIEWED 2017_1013

IF YOU HAVE QUESTIONS WHEN FILLING OUT THIS FORM, PLEASE CONTACT YOUR EDUCATION AND CARE SERVICE

CONFIDENTIAL ENROLMENT FORM

Name of Service

Service No.

Child’s Group

Birth Cer fi cate

Child Health Record (for sigh ng only, if available)

Immunisa on Cer fi cate or Immunisa on Catch-Up Schedule

Legal Order (where applicable)

Medical Management Plan (Anaphylaxis, Asthma or other, where applicable)

Enrolment Date / /

*Commencement Date / /

Service Review Date/s / /

CONFIDENTIAL ENROLMENT FORMThis form must be completed by a parent or guardian who has parental responsibility in rela on to the child. A brief explana on of ‘parental responsibility’ is contained at the end of this form. The Educa on and Care Services Na onal Regula ons 2011 requires an approved provider to keep an enrolment record for each child containing the prescribed informa on in Regula ons 160 to 162. Ques ons marked with an asterisk * are not required by the Regula ons, however, answers you provide to each ques on will assist the service in educa ng and caring for the child.

DEFINITIONSAuthorised Nominee/sAuthorised Nominee means a person who has been granted permission by a family member* to collect the child from the Educa on and Care Service or the family day care educator (Educa on and Care Services Na on Law - Sec on 170(5)).

Family Member/s‘Family Member’ as defi ned in the Educa on and Care Services Na onal Law 2010; Sec on 5 ‘family member’ in rela on to a child, means - (a) a parent, grandparent, brother, sister, uncle, aunt or cousin of the child, whether of the whole blood or half-blood and whether thatrela onship arises by marriage (including a de facto rela onship) or by adop on or otherwise; or(b) a rela ve of the child according to Aboriginal or Torres Strait Islander tradi on; or(c) a person with whom the child resides in a family-like rela onship; or(d) a person who is recognised in the child’s community as having a familial role in respect of the child.

Parental ResponsibilityThe term ‘parental responsibility’ is defi ned in the Family Law Act 1975 as “all du es, powers, responsibili es and authority which, by law, parents have in rela on to children”.

All parents have powers and responsibili es in rela on to their children, which can only be changed by a court order. These powers and responsibili es are referred to as “parental responsibility”. It is not aff ected by the rela onship 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.

confi den ality of enrolment recordsThe approved provider of the Educa on and Care Service must ensure that the informa on in the child’s enrolment record is not divulged or communicated, directly or indirectly, to another person other than as prescribed under Regula ons 181 and 182 of the Educa on and Care Services Na onal Regula ons 2011. This includes, to the extent necessary for the educa on and care of the child or medical treatment of the child; or where expressly authorised, permi ed or required to be given by or under any Act or law; or with the wri en consent of the person who provided the informa on.

Approved Providers are reminded of their requirement to comply with the Privacy Act/s relevant to their State / Territory Jurisdic on in the collec on, use and disclosure, storage and disposal of informa on.

EDUCATION & CARE SERVICE DETAILS

checklistPlease return this form to your Educa on and Care Service along with copies of:




*Age and Gender of Child’s Brothers and Sisters (if applicable)

Name Age Gender

*Any other person(s) living in the child’s home (eg grandparents, step-parents)

Name Known to the child as Rela onship to the child

Family Name Date of Birth / /

Given Names Gender Male Female

*Preferred Name Other

*Child CRN

*Country of Birth *Religion

Language spoken at child’s home

Cultural background of the child and, if applicable, the child’s parents Any special considera ons for the child (e.g. any cultural, religious or dietary requirements or addi onal needs)

PRIMARY FAMILY HOME ADDRESS

No. & Street

Suburb

State Postcode

*Contact Number

*Is the child of Aboriginal and/or Torres Strait islander origin? (please ck)

No, not Aboriginal or Torres Strait Islander Yes, Aboriginal

Yes, Aboriginal and Torres Strait Islander Yes, Torres Strait Islander

CHILD INFORMATION

Customer Reference Number (CRN) from the Family Assistance Offi ce (www.familyassist.gov.au or 136150). Note: Not necessary for Kindergarten or Preschools.




Registered Medical Prac oner/Medical Service Name

Registered Medical Prac oner/Medical Service Address

Phone Number

*Maternal & Child Health (MCH) Centre

*Contact Name

Medicare No Expiry Date / /

*Ambulance Subscrip on No Expiry Date / /

*Healthcare No Expiry Date / /

*Pension No

CHILD’S HEALTH INFORMATION

*Is the child currently a endingor has previously a ended: Counsellor/Psychologist Occupa onal Therapy Pediatrician

Specialist Speech Therapy Die an

Other

If yes, please provide details:

CHILD’S IMMUNISATION STATUS

Has the child been immunised as set out in the Australian Immunisa on Schedule? (Reg. 162 (f)) Yes No

If YES, provide the details by selec ng one of the op ons below:

A aching the Child History Statement from the Australian Childhood Immunisa on Register; OR

A aching an Immunisa on Status Cer fi cate from an immunisa on provider, indica ng the child is age appropriately immunised; OR

A aching a copy of the Immunisa on Record printout from local government; OR

Providing the Child Health Record to the Educa on and Care Service to determine their immunisa on status (excluding VIC & NSW)

If NO, follow the relevant informa on for your state

VIC ONLY: If no, provide the details by selec ng one of the op ons below:

A ach an up to date immunisa on status cer fi cate from an immunisa on provider lis ng any the child is medically unable to have ; OR

A ach a catch-up schedule provided by an immunisa on provider; OR

A grace period elibigility assessment form.

NSW ONLY: If no, provide the details by selec ng one of the op ons below:

A ach an immunisa on (vaccina on) cer fi cate from an immunisa on provider lis ng any the child is medically unable to have ; OR

A ach a cer fi cate provided by an immunisa on provider with an approved vaccina on catch-up schedule; OR

Provide a le er from a registered medical prac oner sta ng the parent/guardian is a conscien ous objector to immunisa on

OTHER STATES: If no, provide a le er from a registered medical prac oner sta ng the parent/guardian is a conscien ous objector to immunisa on.

period of exclusionIn some cases when there is an outbreak of a vaccine preventable disease, unimmunised children will be excluded from the Educa on and Care Service as per the period of exclusion of contacts recommended by the Na onal Health and Medical Research Council. The exclusion periods table can be found at h p://ideas.health.vic.gov.au/guidelines/school-exclusion-table.asp

Immunisa on Record sighted by(from the Child Health Record) (Reg. 162(g)): Name Posi on Date / /

(Statements available from ACIR - Contact: 1800 653 809, www.humanservices.gov.au, or local Medicare offi ce)

Child health record means a record that documents a child’s health and development assessments and immunisa ons.




*FUNDING INFORMATION FOR THIS EDUCATION & CARE SERVICE

CHILD’S MEDICAL INFORMATION

From me to me the Regulatory Authori es seek informa on on the characteris cs of the children and their families who use an Educa on and Care Service. This is used in planning new policies, programs and resources to support services. To help provide accurate informa on please answer the following ques ons by cking the appropriate box indica ng Yes or No:

*Does the child have a developmental delay or disability including intellectual, sensory or physical impairment? Yes No

*Does either parent have a disability? Yes No

*Is the family a single parent family? Yes No

ANAPHYLAXIS (Reg. 162 (c) (ii) & (d))

Has the child been diagnosed as at risk of anaphylaxis? Yes No

Does your child have a auto immune adrenaline device? Yes No

If your child have an auto injec on device, have you supplied to the service a device with a valid expiry date? 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 consulta on with you? Yes No

SPECIFIC HEALTHCARE NEEDS (Reg. 162 (c) (i) & (d))Does the child have any specifi c healthcare needs including any medical condi ons that are relevant to the care & educa on of the child? (e.g. asthma, epilepsy, diabetes etc.) Yes No

If yes please provide details of any specifi c healthcare need/s or medical condi on and any management plan/s or risk minimisa on plan/s to be followed with respect to the specifi c healthcare need/s or medical condi on/s. A ach a copy of any plan/s or addi onal pages if necessary.

If necessary, has medica on been supplied to the service? Yes No

ALLERGIES (Reg. 162 (c) (ii))

Does your child have any allergies? Yes No

If yes please provide details of any allergies and any management plan/s or risk minimsa on plan/s to be followed with respect to the allergy. A ach a copy of any plan/s or addi onal pages if necessary.

If necessary, has medica on been supplied to the service? Yes No

DIETARY RESTRICTIONS (Reg. 162 (e))

Does the child have any dietary restric ons? Yes No

If yes, please provide details of any dietary restric on:

If the service is aware that the child has a specifi c healthcare need, allergy or other relevant medical condi on as iden fi ed above, has a copy of the service’s Medical condi ons policy been provided to the parent or guardian of the child? (Reg 91)

Yes No N/A

Has a communica ons plan been developed to ensure that: (a) relevant staff members and volunteers are informed about the medical condi ons policy, the medical management plan and risk minimisa on plan for the child and (b) the child’s parent can communicate any changes to the medical management plan and risk minimisa on plan for the child. (Reg. 90 (1)(c)(iv))

Yes No N/A

In the case of anaphylaxis you will be provided with a copy of the service’s anaphylaxis management policy. You will be required to provide the service with an individual medical management plan for your child signed by the medical prac oner who is trea ng your child. This will be a ached to your child’s enrolment form. More informa on can be found at www.allergyfacts.org.au




PARENT/GUARDIAN 1 (PRIMARY CARER) PARENT/GUARDIAN 2 (LEAVE BLANK IF NOT APPLICABLE)

Name Name

Address - as per child or: Address - as per child or:

Phone (H) (W) Phone (H) (W)

Mobile *DOB / / Mobile *DOB / /

*Email *Email

* Rela onship to Child: * Rela onship to Child:

Does the child live with this parent? Yes No Does the child live with this parent? Yes No

*Parent 1 CRN *Parent 2 CRN

*EDUCATION *EDUCATION What is the highest year of primary or secondary school the parent/guardian has completed? (please ck one)For persons who have never a ended school, mark ‘Year 9 or equivalent or below’.

What is the highest year of primary or secondary school the parent/guardian has completed? (please ck one)For persons who have never a ended school, mark ‘Year 9 or equivalent or below’.

Year 9 or equivalent or below Year 11 or equivalent or below Year 9 or equivalent or below Year 11 or equivalent or below

Year 10 or equivalent or below Year 12 or equivalent or below Year 10 or equivalent or below Year 12 or equivalent or below What is the level of the highest qualifi ca on the parent/guardian has completed (please ck one)

What is the level of the highest qualifi ca on the parent/guardian has completed (please ck one)

No non-school qualifi ca on Advanced Diploma / Diploma No non-school qualifi ca on Advanced Diploma / Diploma

Cer fi cate I to IV (including trade cer fi cate) Bachelor Degree or above


*OCCUPATION *OCCUPATION What is the occupa on of the parent/guardian?

What is the occupa on of the parent/guardian?

What is the occupa on group of the parent/guardian? What is the occupa on group of the parent/guardian?

A B C D N A B C D N

PARENT/GUARDIAN 3 (LEAVE BLANK IF NOT APPLICABLE) PARENT/GUARDIAN 4 (LEAVE BLANK IF NOT APPLICABLE)

Name Name

Address - as per child or: Address - as per child or:

Phone (H) (W) Phone (H) (W)

Mobile *DOB / / Mobile *DOB / /

*Email *Email

* Rela onship to Child: * Rela onship to Child:

Does the child live with this parent? Yes No Does the child live with this parent? Yes No

*Parent 1 CRN *Parent 2 CRN

*EDUCATION *EDUCATION What is the highest year of primary or secondary school the parent/guardian has completed? (please ck one) For persons who have never a ended school, mark ‘Year 9 or equivalent or below’.

What is the highest year of primary or secondary school the parent/guardian has completed? (please ck one)For persons who have never a ended school, mark ‘Year 9 or equivalent or below’.

Year 9 or equivalent or below Year 11 or equivalent or below Year 9 or equivalent or below Year 11 or equivalent or below

Year 10 or equivalent or below Year 12 or equivalent or below Year 10 or equivalent or below Year 12 or equivalent or below What is the level of the highest qualifi ca on the parent/guardian has completed (please ck one)

What is the level of the highest qualifi ca on the parent/guardian has completed (please ck one)

No non-school qualifi ca on Advanced Diploma / Diploma No non-school qualifi ca on Advanced Diploma / Diploma



*OCCUPATION *OCCUPATION What is the occupa on of the parent/guardian?

What is the occupa on of the parent/guardian?

What is the occupa on group of the parent/guardian? What is the occupa on group of the parent/guardian?

A B C D N A B C D N

PARENT OR GUARDIAN INFORMATION

The above ques ons regarding Educa on & Occupa on are requirements from the Victoria Department of Educa on and Training to assist with the Early Childhood Reform Plan’s “School Readiness” funding , being implemented across the state progressively from 2019. This is for 4 year old funded kinders only.

The ‘Primary’ family is “the family or parent the student mostly live with”. Speak with your service/centre for addi onal family forms if required.

Please ck the appropriate parental occupa on group from the list at the back of this form (Parental Occupa on Group Codes). If the person has not been in paid work for the last 12 months, ck ‘N’. If the person is not currently in paid work but has had a job in the last 12 months, or has re red in the last 12 months, please use their last occupa on to select from the a ached occupa on group list.




COURT ORDERS IN RELATION TO THE CHILD

ADDITIONAL INFORMATION

Are there any:• court orders, paren ng orders or paren ng plans

rela ng to the powers, du es, responsibili es or authori es of any person in rela on to the child or access to the child?• other court orders

rela ng to the child’s residence or the child’s contact with a parent or other person?

No - move onto the Next Sec on Yes - please complete the following:

If you answered Yes to the above, 1. Bring the original order/s for educators to sight and a ach a copy to this enrolment form;2. Please describe the orders and provide the contact details of any person given powers, du es, responsibili es or authori es:

*Please provide any other relevant informa on about the child eg. abili es, interests, likes, dislikes, family tradi ons, home rou nes, paren ng strategies etc.

*Is the child currently a ending or previously a ended:

Kindergarten Playgroup Long Day Care Family Day Care Early Interven on Service Other

If yes - please provide details

*If applicable, which school have you or do you plan to enrol the child?

*Are you willing to have the child photographed to appear in videos, newspapers & other publica ons? Yes No

*To be used in learning & development documenta on - displayed at the service, on Open Days, AGMs or public events? Yes No

*Do you allow sunscreen to be applied to the child while in the care of the Educa on and Care Service? Yes No

*Do you give permission to conduct head lice checks? Yes No

*Please indicate fes vals/celebra ons your family recognises and/or list below any cultural/religious beliefs you wish the educators to be aware of:

Australia Day Birthdays Christmas

Diwali Easter Eid Al-Adha

Mother’s Day Father’s Day New Year

Hanukkah Moon Fes val NAIDOC Week

Name Days Orthodox Easter Ramadan

Tet Winter/Summer Sols ce

Please List others & a ach any specifi c informa on related to the above:

*Do you have any Pets

Name Type

Name Type

Name Type

*Please provide details of any local community services you access with the child? eg Library, Toy Library, Swimming Pool, local park etc.

*Do you have any specifi c skills or a trade that could be of use to the Educa on and Care Service?




AUTHORISED EMERGENCY CONTACTS

AUTHORISATION & DECLARATION

Name Name

Address Address

Phone Mobile Phone Mobile

Email Email

Rela onship to Child: Rela onship to Child:

Authorised to Collect (Authorised Nominee) (Reg. 160(3)(b)(iii)) Authorised to Collect (Authorised Nominee) (Reg. 160(3)(b)(iii))

No fi ca on in the event of an Emergency (Reg. 160(3)(b)(ii)) No fi ca on in the event of an Emergency (Reg. 160(3)(b)(ii))

Authorised to Consent to Medical Treatment (Reg. 160(3)(b)(iv)) Authorised to Consent to Medical Treatment (Reg. 160(3)(b)(iv))

Authorisa on for the administra on of medica on (Reg. 160(3)(b)(iv)) Authorisa on for the administra on of medica on (Reg. 160(3)(b)(iv))

Authorised to authorise an Educator to take the child outside of the premises (Reg. 160 (3)(b)(iv)&(v))


Name Name

Address Address

Phone Mobile Phone Mobile

Email Email

Rela onship to Child: Rela onship to Child:

Authorised to Collect (Authorised Nominee) (Reg. 160(3)(b)(iii)) Authorised to Collect (Authorised Nominee) (Reg. 160(3)(b)(iii))

No fi ca on in the event of an Emergency (Reg. 160(3)(b)(ii)) No fi ca on in the event of an Emergency (Reg. 160(3)(b)(ii))

Authorised to Consent to Medical Treatment (Reg. 160(3)(b)(iv)) Authorised to Consent to Medical Treatment (Reg. 160(3)(b)(iv))

Authorisa on for the administra on of medica on (Reg. 160(3)(b)(iv)) Authorisa on for the administra on of medica on (Reg. 160(3)(b)(iv))



Please list below the details of those people who you have authorised as emergency contacts for the child. This list may be amended at any me. In the event that the parents or guardians cannot be contacted the person/s listed below with authority will be contacted regarding collec ng the child, in event of an emergency involving the child, consent to medical treatment or the administra on of medica on, or to authorise an Educator to take the child outside of the Service premises. Please ck the approriate boxes for each contact to confi rm authorisa ons.

I, (print full name) a person with parental responsibility of the child referred to in this enrolment form (Reg.161):• authorise the Approved Provider, Nominated Supervisor, or an educator or in the case of Family Day Care, the family day care educator, to seek

- medical treatment for the child from a registered medical prac oner, hospital or ambulance service; and - transporta on of the child by an ambulance service; and- if relevant, an authorisa on given under regula on 102 for the Educa on and Care Service to take the child on regular ou ngs.

• agree that I am responsible for any expenses incurred during a medical emergency in rela on to the child;• agree to collect or make arrangements for the collec on of the child if he or she becomes unwell;• understand that in an emergency situa on or where evacua on is necessary that the child may need to leave the Educa on and Care Service under the

direc on and supervision of the approved provider, nominated supervisor or educator;• have read & understood the Educa on and Care Service’s policies including the ‘Payment of Fees’;• declare that the informa on in this enrolment form is true and correct and undertake to immediately inform the Educa on and Care Service in

the event of any change to this informa on;

give permission to contact Maternal Child Health if needed.

Signature of person with parental responsibility of the child Date




PARENTAL OCCUPATION INDEX

Please see the register available at h p://www.educa on.vic.gov.au/school/teachers/management/fi nance/Pages/occupa oncoderegister.aspx

MANAGERS

Chief Execu ves, General Managers & Legislators Chief Execu ves and Managing Directors, Corporate General Manager, Defence Force Senior Offi cer, Local Government Legislator, Member of Parliament A

Farmers & Farm Managers Aquaculture Farmers, Crop Farmers, Livestock Farmers, Mixed Crop, Livestock Farmers A

Specialist Managers Adver sing, Public Rela ons & Sales Managers, Business Administra on Managers, Construc on Managers, Educa on, Health & Welfare Services Managers A

Hospitality, Retails & Service Managers Accommoda on & Hospitality Managers, Retail Managers B

PROFESSIONALS : GENERALLY WITH A BACHELORS DEGREE OR ABOVE Arts & Media Professionals Music Professionals, Photographers, Journalists and Other Writers A

Business, Human Resources & Marke ng Professionals

Accountants, Auditors & Company Secretaries, Financial Brokers & Dealers, and Investment Advisers, Human Resource & Training Professionals, Informa on and Organisa on Professionals, Sales, Marke ng and Public Rela ons Professionals A

Design, Engineering & Science Professionals Architects, Designers, Planners & Surveyors, Engineering Professionals A

Educa on Professionals Early Childhood Teachers, School Teachers, Ter ary Educa on Teachers A

Health Professionals Health Diagnos c & Promo on Professionals, Health Therapy Professionals, Medical Prac oners, Midwifery and Nursing Professionals A

ICT Professionals Business & Systems Analysts, and Programmers, Database & Systems Administrators, and ICT Security Specialists A

Legal, Social & Welfare Professionals Barristers, Judicial and other Legal Professionals, Solicitors, Counsellors, Psychologists, Social Workers, Ministers of Religion A

TECHNICIANS & TRADES WORKERS

Engineering, ICT & Science Technicians Agricultural, Medical & Science Technicians, Building & Engineering Technicians, ICT & Telecommunica ons Technicians B

Automo ve & Engineering Trades Workers Automo ve Electricians & Mechanics, Mechanical Engineering Trades Workers, Panel Beaters, and Vehicle Body Builders, Trimmers and Painters C

Construc on Trades Workers Bricklayers, Carpenters, Joiners, Floor Finishers & Pain ng Trade Workers C

Electrotechnology & Telecommunica ons Trades Workers Electricians, Electronics & Telecommunica ons Trades Workers C

Food Trades Workers Chefs B Bakers & Pastry Cooks, Butchers & Smallgoods Makers, Cooks C

Skilled Animal & Hor cultural Workers Animals A endants and Trainers, and Shearers, Hor cultural Trades Workers C

Other Technicians & Trade Workers Hairdressers, Tex les, Clothing & Footwear Trades Workers C

COMMUNITY & PERSONAL SERVICE WORKERS

Health & Welfare Support Workers Ambulance Offi cers & Paramedics, Dental Hygienists, Technicians & Therapists, Health Workers, Massage Therapists B

Carers & Aides Child Carers, Educa on Aides, Personal Carers & Assistants D

Hospitality Workers Bar A endants & Baristas, Cafe Workers, Gaming Workers D

Protec ve Service Workers Police B Defence Force Members - Other Ranks, Fire & Emergency Workers C

Personal Service Workers Beauty Therapists, Driving Instructors, Travel A endants D

Sports Sports Coaches, Instructors & Offi cials, Sportspersons C Fitness Instructors, Outdoor Adventure Guides D

CLERICAL & ADMINISTRATIVE WORKERS Offi ce Managers & Program Administrators Contract, Program & Project Administrators, Offi ce & Prac ce Managers B

Personal Assistants & Secretaries Personal Assistants, Secretaries, Legal Secretaries C

General Clerical Workers General Clerks, Keyboard Operators D

Inquiry Clerks & Recep onists Call or Contact Centre Informa on Clerks, Recep onists D

Numerical Clerks Bookkeepers, Accoun ng, Financial & Insurance Clerks, Bank Workers D

Clerical & Offi ce Support Workers Couriers & Postal Deliverers, Filing & Registry Clerks, Survey Interviewers D

Other Clerical & Administra ve Workers

Conveyancers & Legal Execu ves B Court & Legal Clerks, Insurance Inves gators, Loss Adjusters & Risk Surveyors C Purchasing & Supply Logis cs Clerks, Debt Collectors, Human Resource Clerks, Inspectors & Regulatory Offi cers D

SALES WORKERS & MACHINERY OPERATORS, DRIVERS & LABOURERS Sales Agents Auc oneers, and Stock & Sta on Agents, Insurance Agents, Real Estate Sales Agents C Sales Representa ves, Sales Assistants, Salespersons & Sales Support Workers

Sales Representa ves, Sales Assistants, Pharmacy Sales Assistants, Retail Supervisors, Checkout Operators D

Machinery Operators, Drivers & Labourers Machines & Sta onery Plant Operators, Road & Rail Drivers, Storepersons, Cleaners & Laundry Workers, Factory Process Workers D

CONFIDENTIAL ENROLMENT FORM...This form must be completed by a parent or guardian who has parental responsibility in rela on to the child. A brief explana on of ‘parental responsibility’

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