Bourke and District Children's Services Enrolment Form

2017 Enrolment Form

(Please note all enrolments are cancelled at the end of 2017 and you must re-apply for 2018)

Bourke and District Children's Services

ADMIN
72 Hope Street
P: 6830 8100 F: 6872 2479 E: admin@bdcs.org.au
PR-00005454

CHILDCARE	MOBILE	PRESCHOOL
Cnr Glen and Oxley Street Phone: 6830 8110 Fax: 6872 1021 Email: childcare@bdcs.org.au SE-00006710	72 Hope Street Phone: 6830 8101 Fax: 6872 2479 Email: mobile@bdcs.org.au SE-00014931	Lot 3, Gorrell Avenue Phone: 6830 8120 Fax 6870 1500 Email: preschool@bdcs.org.au SE-4000505

DEFINITION OF A CHILD WITH A DISABILITY

Does this child have a need for additional assistance in any of the following areas, compared to children of a similar age, that is related to an underlying long-term (lasting for more than 6 months) health condition or disability? The categories include:

• Learning and applying knowledge, education

• Communication

• Mobility

• Self Care

• Interpersonal interactions and relationships

• Other – including general tasks, domestic life, community and social life

This category should only be chosen if the child’s parents/guardians have identified and/or confirmed that the child has a need for assistance in one or more of these areas. The definition of a child with a disability does not include children with a medical condition that is short term (lasts for 6 months or less) or episodic. For example:

• Asthma

• Allergies

• Eczema

• Infectious diseases

DEFINITION OF A CHILD WITHIN A PRIORITY GROUP

Children in a Priority Group are those from the groups listed below.

• Children from culturally and linguistically diverse backgrounds.

• Children with a refugee background who have been subjected to trauma.

• Indigenous children.

• The child's place has been sought by a state or territory child protection worker.

• The child is in the care of the state, or other forms of out of home care.

MANDATORY DOCUMENTATION FOR IMMUNISATION

One of the following documents listed below must be received before a child may be enrolled -

An Australian Childhood Immunisation Register (ACIR) Immunisation History Statement which shows that their child is up to date with their scheduled immunisations, or;
An ACIR** Immunisation Exemption - Medical Contraindication Form (IMMU11) which has been certified by an immunisation provider, or;
An ACIR** Immunisation History form on which the immunisation provider has certified that the child is on a recognised catch-up schedule.

MANDATORY DOCUMENTATION FOR IMMUNISATION

Bourke & District Children’s Services recognises and respects the importance of privacy and confidentiality as an individual right and a basis for building partnerships with families. Our services require personal information to provide appropriate and responsive care to your needs. Our policy has been developed to comply with the Australian Privacy Principles (APPs) (2014) and pursues the highest standard in the protection and preservation of privacy and confidentiality. Please contact Administration on 02 6830 8100 if you would like a copy of our policy.

Child Details
Enrolment Start*

DayMonthYear
Date
Child's Name*

First NameMiddle NameLast Name
Date of Birth*

DayMonthYear
Date
Gender*

MaleFemale
Country of Birth
Language(s) Spoken at Home
If more than one, separate with comma
Home Address*

Street Address

Street Address Line 2

SuburbState

PostcodeCountry
Does Your Child Have a Disability?

YesNo
Are They In a Priority Group?

YesNo
Is Your Chid:

AboriginalTorres Strait IslanderNeither
Childcare Benefit and Rebate
Child's CRN
Parent / Carer Claiming Benefit

First NameMiddle NameLast Name
Parent's CRN
Please note parent and child's CRN are not the same number
Did You Apply For:

Childcare Benefit (CCB)Childcare Rebate (CCR)Job, Edu and Training (JET)
Did You Select It:

To be paid to ServiceA Lump sum Payment at the end of the financial year
Important: You can be getting paid 50% of your Childcare out of pocket costs if eligible! Please make sure that the Parent/Carer Date of Birth and the Parent/Carer CRN are for the person claiming CCB. We ask that you bring your letter from the Family Assistance Office to ensure all data is entered correctly.

CCB & CCR can be claimed as a weekly fee reduction or as a lump sum at the end of the financial year. If you want to receive either of these benefits please apply at your local Family Assistance Office or online at www.centrelink.gov.au
Parent / Carer #1 Details
Parent / Carer #1*

PrefixFirst NameMiddle NameLast Name
Date of Birth*

DayMonthYear
Date
Mobile*
Home Phone*
Language(s) Spoken
Country of Birth
Address*

As per childOther
E-mail*
Place of Employment
Parent / Carer #2 Details
Parent / Carer #2*

PrefixFirst NameMiddle NameLast Name
Date of Birth*

DayMonthYear
Date
Mobile*
Home Phone*
Language(s) Spoken
Country of Birth
Address*

As per childOther
E-mail
Place of Employment
Other Children In The Family*
Person/s Prohibited from Having Contact with The Child
Are there any court orders affecting your child?

YesNo
Person #1

First NameLast Name
Person #2

First NameLast Name
Emergency Contact
- Parents/Carers listed will be the first emergency contact and authorised pick up unless otherwise notified in writing.
- Using the boxes below, list at least 2 people authorised to collect the child or that we may call if we cannot find you in an emergency. Please include regular babysitters. Please note those listed must be over 18 years of age.
- If a person has not been authorised by you, your child will not be released into their care. A written authorisation is required if your child is to be collected by a person not listed on this form.
- If your child has not been collected by the closing time of the service or their nominated session, those persons nominated as ‘emergency contacts’ will be asked to collect your child.
Emergency Contact 1

First NameLast Name
Address

Street Address

Street Address Line 2

SuburbState

PostcodeCountry
Phone Number
Email
Relationship to Child
Authorised Nominee

EmergencyCollectionMedicalExcursion
Emergency Contact 2

First NameLast Name
Address

Street Address

Street Address Line 2

SuburbState

PostcodeCountry
Phone Number
Email
Relationship to Child
Authorised Nominee

EmergencyCollectionMedicalExcursion
Preschool Only - Bus Transport
I give permission for my child to be transported, as required, on either of the Preschool buses for the purpose of attending Preschool. I understand that this consent will cover all Preschool terms.

I understand that this consent also covers excursions.
PLEASE TICK IF YOU DO NOT WANT YOUR CHILD TO TRAVEL ON THE PRESCHOOL BUS FOR EXCURSIONS

Signed
Pick Up Address

Street Address

Street Address Line 2

SuburbState

PostcodeCountry
Drop Off Address

Street Address

Street Address Line 2

SuburbState

PostcodeCountry
MEDICAL AND HEALTH INFORMATION:
Is Your Child's Immunisation Up To Date?*

YesNo
Is Your Child's Immunisation On a Backup Schedule?*

YesNo
If yes, please upload your child’s ACIR Immunization History Statement

Upload a File

Cancelof
Name of Doctor

First NameLast Name
Telephone
Address of Doctor/Medical Service

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Medicare No
Health Fund
Does the child have any allergy or sensitivity? If yes, a management plan is to be attached and signed by a doctor.

AnaphylaxisAsthmaDiabetesDustEpilepsyEggsPeanutsFishShellfishTree NutsWheatSoyCow's MilkFruit
Allergy/Sensitivities Management Plan

Upload a File

Cancelof
Does the child have any dietary restrictions? If yes, please describe:
Does the child have any other special considerations (i.e. cultural, religious, etc.)?
In the event of my child developing a temperature,*

I giveI DO NOT give
permission for Bourke & District Children’s Services Inc staff to administer liquid paracetamol as per recommended dosage by age. I am responsible for supplying the liquid paracetamol. BDCS DO NOT keep a supply on hand. I understand that this permission will be applicable for any excursions that my child may attend.

N.B Please note if your child’s temperature reaches 38°C they will be sent home.
Signed
Enrolment Details

Please tick and complete the areas of the Centres you would like your child to attend. Please note we can’t guarantee days but will do our best to accommodate.
4 YEAR OLD PROGRAM – Opening Monday 6th February 2017
Which class would you prefer?

Mondays & Tuesdays 9.00am - 5.00pmThursdays & Fridays 9.00am - 5.00pm
Will your child be enrolling in Kindergarten in 2018?

YesNo

3 YEAR OLD PROGRAM – Opening Wednesday 15th February 2017

Children must have turned 3 to begin program

Wednesdays 9.00am – 5.00pm

CHILDCARE - Opening Thursday 5th January 2017

	Mon	Tues	Wed	Thurs	Fri	Casual
(AD) 8.15 – 5.15
(AM) 8.15 – 1.15
(PM) 1.15 – 5.15

MOBILE – Opening Monday 6th February 2017
Do you Live:

In TownRural
Are you enrolling:

One ChildOr a Family
Please list the sessions you will be attending:

EXPRESION OF INTEREST FOR BEFORE AND AFTER SCHOOL CARE (BASC)

	Mon	Tues	Wed	Thurs	Fri	Casual
Before School 8.15am – 9.00am
After School 3.00pm – 5.30pm

Fees & Payment

PRESCHOOL *Preschool Fees are income based, to be charged on level 1-3 you MUST provide proof of income
	Income Brackets (per annum)	Daily fee amount for full day (9:00am-5:00pm)
Level 1	$0.00 - $21 000	$9.00
Level 2	$21 001 - $30 000	$16.00
Level 3	$30 001 - $48 837	$20.00
Level 4	> $48 837	$24.00

CHILDCARE
	AD UNDER 3 YEARS OLD (8.15 - 5.15)	AD OVER 3 YEARS OLD (8.15 - 5.15)	HALF DAY (8.15 - 1.15) or (1.15 - 5.15)
Fees	$90.00	$82.00	$50.00
Late Fee	$1.00 per minute (after either 1.15 - AM session or 5.15 AD or PM session
Bond	$50.00 per child (new enrolments). Bond is refunded or applied to fees owning on termination of enrolment.
Casual	All casual bookings will be charged an extra $2.00 for each session
Please Note:	Children attending a PM session before 1.15pm will be charged an AD session fee

Mobile (Annual)
Town	One Child	$15.00	Family	$30.00
Rural	One Child	$10.00	Family	$20.00
Note: If not a member, the cost persessionis $1.00 per child or $2 per family.

I agree to pay the calculated fees on time and acknowledge that if my fees are overdue BDCS may refer my account to a debt collection agency and cancel my child’s enrolment. I will be responsible for any fees charged by the debt collection agency. For more information please refer to the fees policy.
Name*

PrefixFirst NameMiddle NameLast Name
Signed
DayMonthYear
Date
Postal or Email Address for Billing*
Fee Assistance Application Form

(Please complete the following if total of both incomes are below $48837)
The following section helps BDCS assess the level of your eligibility for this assistance. The fee assistance is provided by way of fee reduction. Proof of your gross family income will determine eligibility for this assistance. If no proof of income is provided you will be assessed as a level 4 income.

Eligibility for Fee Assistance

a) Include all details for spouse or partner residing with the parent responsible for the child/children.

b) If your only source of income is Centrelink payments please provide a letter from Centrelink detailing income.

c) Include the value of cash and non-cash benefits from employment or self-employment.

d) Proof of income can be current original or certified copy, including:
- An Income Statement from Centrelink
- Letter from accountant
- Pay slip (standard)
- Letter from an employer – outlining income
- Taxable income as shown on notice of assessment from the Australian Tax Office (ATO)
Gross Income Parent/Carer #1
Proof of income supplied

YesNo
Gross Income Parent/Carer #2
Proof of income supplied

YesNo
Total Gross Family Income
DECLARATION BY FAMILY

1) The information given in this form is correct for the current time.
2) I / We have provided all evidence relating to my / our gross income.
3) I / We will advise the service of any changes to the information provided in this application, which would affect eligibility or the level of subsidy provided.
4) I / We are aware that eligibility must be reassessed periodically and a new application be completed when required.
Parent/Caregiver*

Signed
Spouse/Partner*

Signed
Authorisations

Parent/Carer Statement and Authorization*

	Yes	No	N/A
I will, if required, produce evidence in support of this application, and I understand that I am to present this information annually.
I acknowledge that the 3 services endeavour to be NUT FREE and will not send foods such as Peanut Butter/Nutella or other nut based spreads or nuts with my child, as this may cause life threatening risks to other children attending with allergies to these products.
I give permission for sunscreen to be applied to my child when going outdoors.
I give permission for Insect Repellent to be applied to my child when necessary. I will inform the staff if my child is allergic to any type of repellent. I am also aware that BDCS uses a homemade repellent which contains Dettol, Methylated Spirits, baby oil & citronella oil as per the Pharmacist’s recipe.
BABIES/TODDLERS: I give permission to the staff to apply the cream I supply to treat nappy rash as required.
I give permission for my child to be involved in Publicity, e.g. Website, Facebook, Newsletters, Newspaper, Brochures, Photos etc.
I hereby consent to the Director or their designated representative to arrange First Aid/ Medical and/or an ambulance in the case of an emergency. If I cannot be contacted, I accept the emergency service will be at the nearest appropriate public hospital or medical centre and will take responsibility for associated costs.
I undertake to advise BDCS of any changes (including changes in income that may affect CCB/CCR) to information on this form which would affect the level of assistance provided and also any special arrangements in relation to the care of my child.
I agree to pay the calculated fees on time and acknowledge that in case the payment of my fees is two weeks overdue BDCS may cancel my child’s enrolment. If my fees are not paid on time BDCS has the right to contract a collection agency and/or solicitors to recover the monies outstanding and I will be liable for any costs, charges, commissions and expenses payable by BDCS to the collection agency and/or solicitors relating to the recovery of monies owed by me.
If my child is attending Kindergarten in the year following this enrolment, I give permission for BDCS staff to provide information regarding my child, to the school that my child will be attending.
2017 Enrolment – This enrolment form only applies to the 2017 year. Your enrolment is automatically cancelled at the end of each year. You must re-enrol for the following year. Enrolments are confirmed only if there is availability.
CHILDCARE - I agree to give a minimum of two weeks’ written notice of termination of my child’s enrolment or I will be charged fees as per the attendance stated on enrolment.
I understand my child’s booked session secures their placement in the Centre and unless one week (7 days) written notice is given I will be charged fees for the session. This is for any absence including holidays, sickness etc. If a week’s written notice is received I will be charged half fees.
PRESCHOOL – I acknowledge that I need to pay fees for my child’s placement at Preschool regardless of whether my child is sick or absent for any reason such as holidays etc during the school term. Fees are charged per term and the full term’s fees are due once the new term has commenced and you have not advised us of cancellation of the place.
MOBILE – I agree that when I am attending a session with my child I accept responsibility for my child.

Signed
Date

DayMonthYear
Date
Should be Empty:

2017 Enrolment Form

DEFINITION OF A CHILD WITH A DISABILITY

DEFINITION OF A CHILD WITHIN A PRIORITY GROUP

MANDATORY DOCUMENTATION FOR IMMUNISATION

MANDATORY DOCUMENTATION FOR IMMUNISATION

Child Details

Childcare Benefit and Rebate

Parent / Carer #1 Details

Parent / Carer #2 Details

Person/s Prohibited from Having Contact with The Child

Emergency Contact

Preschool Only - Bus Transport

MEDICAL AND HEALTH INFORMATION:

Enrolment Details

Fees & Payment

Fee Assistance Application Form

Authorisations