New Enrolment Form 1

This form must be completed by a parent or guardian who has lawful authority to the child. A brief explanation of lawful authority is contained at the end of this form. The licensed children's service must collect the information in this form, as required by the Children's Services Regulations 1988 (Regs)

Child's Details

First Name:

Family Name:

Date of Birth

DayMonthYear

Home Address:

Gender

Mother's Details

Family Name:

First Name:

Address:

Occupation:

Date of Birth

DayMonthYear

Home Telephone Number

Work Telephone Number

Mobile Telephone Number

Email Address

Does the Child live with the Mother?

Father's Details

Family name:

First Name:

Address:

Occupation:

Date of Birth

DayMonthYear

Home Telephone Number

Work Telephone Number

Mobile Telephone Number

Email Address

Does the Child live with the Father?

Guardian's Details (If Applicable)

Family Name:

First Name:

Address:

Occupation

Date of Birth

DayMonthYear

Home Telephone Number

Work Telephone Number

Mobile Telephone number

Email Address

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Court Orders relating to this Child:

Are there any court orders to the power and responsibilities of the parents in relation to the child or access to the child?

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.
**Consent to the medical treatment of the child.
**Request or permit the administration of medication to the child.
**Collect the child, AND/OR b) Give these powers to someone else,
Please describe these changes and provide the contact details of any person given these powers:

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Emergency Contact/Pick Up Details

There may be times when the child has an accident, injury, trauma or illness and the parents or guardians cannot be contacted. To deal with these situations the children's service should notify one of the following people who are authorised to collect and care for the child, after accident, injury, trauma or illness.

Your consent is required for other people to collect the child from Juggles on your behalf. Please list the details of those people who can collect the child below. In the event that the child is not collected from Juggles and the parents or guardians cannot be contacted, this list will also be used to arrange someone to collect the child.

Full Name:

Address:

Home Telephone Number

Work Telephone Number

Mobile Telephone Number

Relationship to Child

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Full Name:

Address:

Home Telephone Number

Work Telephone Number

Mobile Telephone Number

Relationship to Child

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Full Name:

Address:

Home Telephone Number

Work Telephone Number

Mobile Telephone Number

Relationship to Child

Child's Medical and Health Information

Name of Doctor

Name of Medical Service

Address of Medical Service

Telephone No. of Medical Service

Medicare Number

Ambulance Subscription Number

Does your child have any allergy or sensitivity?

Does the child have any medical conditions and needs (e.g. Asthma, Diabetes)

If Yes - What management procedure are to be followed? Provide Juggles with a copy of the plan. Provided by your Doctor

Does your child have any dietary restrictions?

If Yes - The Following restrictions apply:

Child's Immunisation Record:

Has your child been immunised?

If Yes, provide the details on the first visit to the centre by:
** Bringing the original Immunisation Record from the Child Health Record book
OR
** Bringing an original Immunisation Record printout from local government
OR
** Bringing an original Child History Statement from the Australian Childhood Immunisation Register. Child's immunisation record to provide the dates of immunisation received

You may have also purchased additional immunisations for your child.

If so, please provide the dates these have been given.

If there is anything else that Juggles should know about your child, (eg excessive fears, favourite activities) attending early childhood services etc...

Has your child previously attended:

If Yes - Name of Centre:

Declaration and consent to emergency medical treatment:

We will ask you to sign the Declaration -
- on your first visit to Juggles Occasional Childcare. below I (your 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 Juggles in the event any change to this information;
** I agree to collect or make arrangements for the collection of the child referred to in this enrolment form if s/he becomes unwell at Juggles;
**I consent to the staff of Juggles seeking, or where appropriate, administering, such emergency medical, hospital, dental, or ambulance services, or treatment as is reasonably necessary and that I will reimburse any necessary expenses incurred by Juggles Occasional Childcare;
I understaned that in an emergency situation or fire drill where evacuation
**is necessary that my child may need to leave the preschool/childcare premises under the direction and supervision of staff;
** I have read and understand the Juggles Occasional Childcare Centre's policies and fees.

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Where did you hear about Juggles?

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Lawful Authority

Parents - All parents have powers and responsibilities in relation to their children,which can only be changed by a court order. The Children's Services Regulations 1998 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 under the Family Law act, may take away the authority of a parent to do something or may give it to another person.

Guardians - A guardian of a child also has lawful authority. authority of a parent to do something or may give it to another person. A legal guardian is given lawful authority by a court order. The definition of "guardian" under the Children's Services Act 1996 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 the child lives with who has day to day care and control of the child.

PRIVACY NOTIFICATION - Juggles Occasional Child Care centre for uses the enrolment form to collect personal information the purposes of program enrolment and statistical recording uses the enrolment form to collect personal information. The information may be shared with funding agencies (Vic. & Fed. Govts.) and administrators for operational purposes only. The information will not be disclosed to any other party except as required by law. You are able to amend or correct information on request by contacting the Centre Coordinator.

Juggles Confidential Enrolment Details.