Kekeco Childcare Pty. Ltd. - Long Day Care and Kindergarten Enrolment

CONFIDENTIAL ENROLMENT FORM

This form must be completed by a parent or guardian who has parental responsibility in relation to the child. A brief explanation of 'parental responsibility is contained below. The Education and Care Services National Regulations 2011 requires an Approved Provider to keep an enrolment record for each child containing the prescribed information in Regulations 160, 161 and 162. Questions marked with an asterisk * are required by the Regulations and failure to complete these sections will mean that the form cannot be lodged electronically.

Education & Care Service Details

Name of Service where care is required *

Dudley Street Childcare and Kindergarten, WallanFerguson Street Kindergarten and ELC, BroadfordSutherland Street Childcare and Kindergarten, Kilmore

Enrolment Date

Commencement Date *

Service Review Date (Office use)

Will your child attend Kindergarten at our Service? *

Yes NoNot decided at this time.

Which Kindergarten Program will your child attend in 2024-2025-2026? *

3 Year Old Kindergarten4 year old KindergartenChild not yet eligible for KindergartenChild will attend Kindergarten at another site.N/A child will attend Primary School next year

1. Child Information

Given Names *

Family Name *

Child's Address *

Date of Birth *

Child's Country of Birth *

If the child was not born in Australia Date of Arrival in Australia

Primary School will your child attend?

Year your child will start Primary School? *

Language spoken at home (if not English)

What is your family Cultural Background? *

Is the family a single parent family? *

YesNo

Are there any Court Orders /Parenting Plans etc. *

YesNo

If there are please attach a copy of the Court Orders and/or Parenting Plan

Please provide us with the latest copy of any Court Orders or Parenting Plans (Refer Section 15) *

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Does the child have their own Child Disability Health Care Card? *

NoYes

2. Is the child Aboriginal and/or Torres Strait Islander?

Is the Child Aboriginal and/or Torres Strait Islander *

No, not Aboriginal or Torres Strait IslanderYes, Aboriginal Yes, Aboriginal and Torres Strait IslanderYes, Torres Strait Islander

What Mob does your family belong to?

3. Definitions

Parental Responsibility : The term Parental Responsibility is defined in the Family Law Act 1975 as being "all duties, powers, responsibilities and authority which, by law, parents have in relation to children" All parents have powers and responsibilities in relation to their children, which can only be changed by Court Orders. These powers and responsibilities are referred to "parental 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, as issued under the Family Law Act,may take away the authority of a parent to do something, or may give it to another person.

Authorised Nominee/s : Authorised Nominee means a person who has been granted permission by a parent or family member* to collect the child from the Education and Care Service or the family day care educator (Education and Care Services National Law - Section 170(5))

Family Member/s as defined in the Education and Care Services National Law 2021; Section 5:

(a) a parent, grandparent, brother, sister, uncle, aunt or cousin of the child, whether of the whole blood or half-blood and whether that relationship arises by marriage (including a de factor relationship) or by adoption or otherwise; or

(b) a relative of the child according to Aboriginal or Torres Straight Islander tradition; or
(c) a person with whom the child resides in a family-like relationship; or
(d) a person who is recognised in the child's community as having a familial role in respect of the child.

Guardian: A Guardian of a child also has lawful authority. A Legal Guardian is given lawful authority by a court order. Then definition of guardian under the Education and Care Services National Law 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 who has day to day care and control of the child.

Bookings: Permanent Bookings attract fees for all attendance and non attendance days (including sick days, public holidays etc.)

4. People Living with the Child, including Parents, Siblings, Grand Parents etc

Does the child live with Parent?Guardian 1? *

YesNoAs per Court Orders

Is the child linked to Parent/Gaurdian 1 for Childcare Subsidy (CCS)? *

YesNo

Parent/Guardian 1 First Name *

Parent/Guardian 1 Last Name *

Parent/Guardian 1 CRN *

Parent/Guardian 1 Phone Number *

Parent/Guardian 1 Email address *

Parent/Guardian 1 Date of Birth *

Parent/Guardian 1 Home Address *

Country of birth of Parent/Guardian 1 ? *

Birth Language of Parent/Guardian 1

Date Parent/Guardian 1 Arrived in Australia DD/MM/YY

Does this Parent/Guardian hold a Commonwealth Concession Card *

No Yes

If the Parent/Guardian holds a Commonwealth Concession Card what type of card do they hold??

Autorisations for Parent 1 *

Authorised to Collect the child ( Authorised Nominee) (Reg. 160 (3) (b) (iii)Notification in the event of an Emergency ( Reg. 160 (3) (b)(ii)Authorised to Consent to Medical Treatment ( Reg. 160 (3) (b) (iv)Authorisation for the administration of medication (Reg. 160 (3) (b) (iv))Authorised to authorise an Educator to take the child outside the premises ( Reg. 160 (3) (b) (iv) & (v)

Parent/Guardian 2 Given Name *

Parent/Guardian 2 Last Name *

Parent/Guardian 2 CRN

Parent/Guardian 2 Phone Number *

Parent/Guardian 2 Email address

Parent/Guardian 2 Date of Birth *

Parent/Guardian 2 Address *

Does the child live with Parent/Guardian 2 *

YesNoAs per Court Orders

Is the child linked to Parent 2 for Childcare Subsidy (CCS)? *

YesNo

Country of Birth of Parent/Guardian 2 ? *

Date Parent/Guardian 2 Arrived in Australia DD/MM/YY

Birth language of Parent/Guardian 2

Name of Person living with child (other than parents)

Known to the child as

Age and gender of siblings ( if applicable )

Relationship to the child

AUTHORISATIONS FOR PARENT/GUARDIAN 2 *

Authorised to Collect the child ( Authorised Nominee) (Reg. 160 (3) (b) (iii)Notification in the event of an Emergency ( Reg. 160 (3) (b)(ii)Authorised to Consent to Medical Treatment ( Reg. 160 (3) (b) (iv)Authorisation for the administration of medication (Reg. 160 (3) (b) (iv))Authorised to authorise an Educator to take the child outside the premises ( Reg. 160 (3) (b) (iv) & (v)

5. The information below is required for all Enrolments.

PARENT 1 Education - what is the highest year of primary or secondary school that Parent 1 has completed? *

Year 9 or equivalent or belowYear 10 or equivalent or belowYear 11 or equivalent or belowYear 12 or equivalent or below

PARENT 1 What is the highest Tertiary Qualification completed *

No Non School qualification Certificate 1- IV (including Trade Certificate)Advanced Diploma/DiplomaBachelor Degree or above

Parent 1/Guardian Occupation *

PARENT 2 Education - what is the highest year of primary or secondary school that Parent 2 has completed? *

Year 9 or equivalent or belowYear 10 or equivalent or belowYear 11 or equivalent or belowYear 12 or equivalent or below

PARENT 2 What is the highest Tertiary Qualification completed. *

No Non School qualification Certificate 1- IV (including Trade Certificate)Advanced Diploma/DiplomaBachelor Degree or above

Parent/Guardian 2 Occupation *

The list of Parental Codes is available on the link below

https://sutherlandstreet.com.au/forms/

6. Authorised Emergency Contacts (Department of Education requires 4 contacts plus parents)

Please list below the details of those people who you authorise as emergency contacts for the child. This list may be amended at any time. In the event that the parent/guardians cannot be contacted the person/s listed below, with Authority, will be contacted regarding collecting the child, in the event of an emergency involving the child, consent to Medical treatment or the administration of medication, or to authorise an Educator to take the child outside the service premises. Please tick the appropriate boxes for each contact to confirm authorisation.

It is a Department of Education requirement that we have all four Authorised Persons details completed, in addition to one or both Parents/Guardians, Including addresses for Authorised Persons.

Authorised Person 1 First Name *

Authorised Person 1 Last Name. *

Authorised Person 1 Address *

Authorised Person 1 Phone Number *

Authorised Person1 Email

Authorised Person 1 has the Authority to approve the following: *

Authorised to Collect the child ( Authorised Nominee) (Reg. 160 (3) (b) (iii)Notification in the event of an Emergency ( Reg. 160 (3) (b)(ii)Authorised to Consent to Medical Treatment ( Reg. 160 (3) (b) (iv)Authorisation for the administration of medication (Reg. 160 (3) (b) (iv))Authorised to authorise an Educator to take the child outside the premises ( Reg. 160 (3) (b) (iv) & (v)

Authorised Person 2 First Name *

Authorised Person 2 Last Name *

Authorised Person 2 Address *

Authorised Person 2 Phone Number *

Authorised Person 2 Email

Authorised Person 2 has the Authority to approve the following: *

Authorised to Collect the child ( Authorised Nominee) (Reg. 160 (3) (b) (iii)Notification in the event of an Emergency ( Reg.160 (3) (b)(ii)Authorised to Consent to Medical Treatment ( Reg. 160 (3) (b) (iv)Authorisation for the administration of medication (Reg. 160 (3) (b) (iv))Authorised to authorise an Educator to take the child outside the premises ( Reg. 160 (3) (b) (iv) & (v)

Authorised Person 3 First Name *

Authorised Person 3 Last Name. *

Authorised Person 3 Address *

Authorised Person 3 Phone Numbers *

Authorised Person 3 Email address

Authorised Person 3 has the Authority to approve the following: *

Authorised to Collect the child ( Authorised Nominee) (Reg. 160 (3) (b) (iii)Notification in the event of an Emergency ( Reg.160 (3) (b)(ii)Authorised to Consent to Medical Treatment ( Reg. 160 (3) (b) (iv)Authorisation for the administration of medication (Reg. 160 (3) (b) (iv))Authorised to authorise an Educator to take the child outside the premises ( Reg. 160 (3) (b) (iv) & (v)

Authorised Person 4 First Name *

Authorised Person 4 Last Name *

Authorised Person 4 Address *

Authorised Person 4 Phone Numbers *

Authorised Person 4 email address

Authorised Person 4 has the Authority to approve the following: *

Authorised to Collect the child ( Authorised Nominee) (Reg. 160 (3) (b) (iii)Notification in the event of an Emergency ( Reg.160 (3) (b)(ii)Authorised to Consent to Medical Treatment ( Reg. 160 (3) (b) (iv)Authorisation for the administration of medication (Reg. 160 (3) (b) (iv))Authorised to authorise an Educator to take the child outside the premises ( Reg. 160 (3) (b) (iv) & (v)

7. Authorisations Panel

I, Parent/Guardian 1 as shown on the Enrolment Form confirm that I authorise the Approved Provider, Nominated Supervisor or an educator to seek *

Medical treatment for the child from a registered Medical Practitioner, hospital or ambulance service; and transportation by an ambulance service if required; andI agree that I am responsible for any expenses incurred during any medical emergency in relation to the child. I agree to collect or make arrangements for the collection of the child if he or she becomes unwell.I understand that in an emergency situation or where evacuation is necessary that the child may need to leave the Education and Care service under the direction and supervision of the Approved Provider, Nominated Supervisor or educators.I consent to the Education and Care Service contacting Maternal Child Health if needed.I have read and understood the Education and Care Services Policies including Payment of Fees Policy.I declare that the information in this Enrolment Form is true and correct and undertake to immediately inform the Education and Care service in the event of any change to this information.If applicable, I give permission for any Allergy or Medical Condition Management plans to be displayed for the child.

Parent/Guardian 1 *

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Date:

8. Child's Health Information

Medicare No *

Expiry Date Medicare *

Medical Practioner *

Address of Medical Practitioner

Medical Practitioner Contact *

Ambulance subscription No *

Expiry Date Ambulance Cover *

Is the currently attending or has previously attended additional professional assistance? i.e. psychologist, Speech therapist, etc.

YesNo

Please provide details

Please provide any Management Plans if applicable

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9. CHILD'S IMMUNISATION STATUS

In February 2018 it became a legal requirement for all children attending childcare and Kindergarten in Victoria to be fully vaccinated, unless they have a medical exemption. Please refer to Dept of Health for more details.

https://www2.health.vic.gov.au/public-health/immunisation/vaccination-children/no-jab-no-play/immunisation-enrolment-toolkit.

Has the child been immunised as set out in the Australian Immunisation Schedule?Reg. 162. (f)) *

YesNoCatch up programMedical Exemption

Please attach Immunisation History Statement from the Australian Childhood Immunisation Register (AIR) *

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If No, please attach an up to date Immunisation History Statement which shows your child is Medically unable to be immunised. *

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If your child is on a Catch Up Plan Please attach a commenced and on track Catch Up statement provided by an Immunisation provider. *

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If your child has a Medical Exemption- please provide a copy of the Immunisation History Statement showing the exemption. *

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Signature of Staff member who has sighted the Immunisation History Statement for this child.

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Date of sighting of IHS at the Early Childhood Education and Care service.

10. SPECIFIC HEALTHCARE AND DIETARY NEEDS- (Reg. 162 (c) (i) & (d)

Does your child have any other specific Healthcare or Dietary requirements?? *

YesNo

Please provide us with as much detail as possible on what these specific dietary requirements are.

Does your child have any Allergies, dietary intolerances or Medical Issues which we need to know about? *

Is the condition: *

MildModerateSevere

Please provide us with as much detail as possible on possible Allergies etc.

11. Anaphylaxis Management (Reg. 162(c) (ii) & (d)

Has your child been diagnosed as at risk of anaphylaxis? *

YesNo

Does your child have an auto injection adrenaline device? *

YesNo

If your child has an auto injection adrenaline device, have you supplied the device to the service with a valid expiry date?

YesNo

Please attach a current Anaphylaxis Medical Management Plan, signed by a Medical Practitioner.

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Has a Risk Management Plan been completed by the service, in consultation with you?

YesNoStill being prepared

Does your child have dietary requirements related to their Anaphylaxis?

YesNo

Does your child have environmental requirements in relation to their Anaphylaxis?

YesNo

A copy of the service's Anaphylaxis Management Policy is available on the Service Website link below, Parent access on Childcarers and printed copies are available at the front desk.

https://sutherlandstreet.com.au/wp-content/uploads/2020/02/Anaphylaxis-Management-Policy-QA2-V2.6.19.pdf%20

Please provide any supporting documents relating to the issues above.

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12. Allergy Management

Does your child have a diagnosed Allergy? *

Yes No

A copy of ASCIA Allergy Action Plan is available on

http://%20https://www.vu.edu.au/sites/default/files/allergy-action-plan.pdf

Allergy Action Plan completed and detailing these issues.

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Management Plan to be completed by parent

13. Asthma Management

Has your child been diagnosed with Asthma ? *

YesNo

If your child has been diagnosed with suffering from Asthma, an Asthma Management Plan is required before the child can commence care with us.

Please have a Medical Practitioner complete the form and attach to the Enrolment application.

https://d8z57tiamduo7.cloudfront.net/resources/341-NAC-Asthma-Action-Plan-2015_Writeable.pdf

Asthma Management Form - completed and signed by Medical Practitioner.

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14. Medical Condition Management

Has your child been diagnosed with a Medical Condition? *

YesNo

Please provide us with a Medical Practitioner Letter of Diagnosis

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15. COURT ORDERS IN RELATION TO THE CHILD

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 have lived together or are married.

A Court Order, such as an Order under the Family Law Act, may take away the authority of a parent to do something, or may give it to another person.

Guardian

A Guardian of a child also has lawful authority. A Legal Guardian is given lawful authority by a court order. Then definition of guardian under the Education and Care Services National Law 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 who has day to day care and control of the child.

COURT ORDERS- Are there any Court Orders, Parenting Orders or Parenting Plans relating to the powers, duties, responsibilities or authorities of any person in relation to the child or access to the child? *

YesNo

If you Answered "Yes" above. Please attach a full copy of the order to this Enrolment Form and bring the original order for the educators to sight. NOTE: should this Order change in the future then we require an updated copy as soon as possible after issuance. *

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16. ADDITIONAL INFORMATION ABOUT THE CHILD AND FAMILY.

Do you give permission for Learning and Developmental Checklists to be completed for your child? *

YesNo

Do you allow suncreen to be applied to the child while in the care of the Education and Care Service? *

YesNo

Do you allow your child Limited access to Screen Time for Educational Purposes ?

YesNo

Do you give permission to conduct head lice searches if needed *

YesNo

Does the child have a developmental delay or disability, including intellectual or physical impairment? *

Yes No

If you answered Yes to the Developmental Delay Question please provide any diagnosis or other documents to enable us to support your child. *

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Is the Child currently attending another service or Early Childhood group? *

No, My child does not attend any other service3 year old Kindergarten at another service4 year old Kindergarten at another servicePlaygroupLong Day Care at another serviceEarly Intervention ServiceOther ( please explain)

17. Photo Permission Form

Family Permits Photos to be taken of the Child? *

YesNo

Comments/Notes

Signed by the Primary Care Parent *

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Date Permissions applicable from *

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