Family Name                    

Home Address   

Home Phone       

Have you used our program previously?    Yes No

Are you registered with Centrelink?    Yes No

Are you enrolling more than one child?    Yes No

Please complete one form for each child being enrolled

_________________________________________________________________________________________

Child Details

First Name       

Surname       

Gender      Male Female

D.O.B        01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 January February March April May June July August September October November December 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

School Grade        Prep Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Grade 6

Dates the child will be attending the School Holiday program:   Mon 30 June    Tues 31 June    Wed 1 July    Thurs 2 July    Fri 3 July

(Please select all applicable)                                                      Mon 6 July        Tues 7 July      Wed 8 July    Thurs 9 July    Fri 10 July

Is English spoken at home?        Yes No

If no please explain   

Is the child of Aboriginal            Yes No

and/or Torres Strait Islander

descent?

Centrelink CRN       

Doctor       

Medical Centre       

Centre Phone       

Ambulance Cover?        Yes No

Private Health?           Yes No

Food allergy/intolerance        Yes No

or dietary restrictions?

Please explain      

Medical Notes       

Please explain

_________________________________________________________________________________________

Parent Details

Mother/Guardian full name       

Address (if different from above)       

Does the child live with you?          Yes No

Mobile       

Occupation       

Place of employment       

Business Phone       

Email       

Father/Guardian full name       

Address (if different from above)       

Does the child live with you?          Yes No

Mobile       

Occupation       

Place of employment       

Business Phone       

Email       

_________________________________________________________________________________________

DECLARATION

By submitting this form, a person with lawful authority of the child referred to in this enrolment you declare that:

• That the information provided for the purpose of this enrolment is true and correct and that you 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 he/she becomes unwell at the service.

• Consent to the staff of the children's service seeking and where appropriate, administering such emergency medical treatment as is reasonably necessary and you agree that you will reimburse any necessary expenses incurred by the children's service.

• You agree to follow the fee payment structure and you understand that if you do not follow it your children may not be allowed to attend the program.

• You have read and understood this declarations

  I Agree I do no agree