Enrolment Form: SMOOSH program
Child's name
*
First Name
Last Name
Child's gender
*
Male
Female
Other
Child's date of birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Child's place of birth
*
Aboriginal or Torres Strait Islander?
*
Yes
No
Child's current home address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
School child currently attends
*
Class?
*
Child's CRN number
*
SMOOSH location your child will attend
*
Eastlakes Public School
Bankstown South Infants School
Hampden Park Public School
Bankstown Public School
Birrong Public School
Permanent days attending
Monday
Tuesday
Wednesday
Thursday
Friday
Please specify whether you'd like before-school, after-school, or BOTH for these day(s), e.g. "Tuesday BOTH" or "Tuesday after school"
Casual day(s) attending
Monday
Tuesday
Wednesday
Thursday
Friday
Please specify whether you'd like before-school, after-school, or BOTH for these day(s), e.g. "Tuesdays BOTH" or "Tuesdays after school"
Parent/ carer information
Parent/ carer 1
*
First Name
Last Name
Date of birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email address
example@example.com
Relationship to child
*
Mother
Father
Carer
Home address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home phone number
-
Area Code
Phone Number
Work phone number
-
Area Code
Phone Number
Mobile phone number
*
Occupation or course of study
Employer or place of study
Business address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
CRN number
*
Country of birth
*
Language/s spoken
*
Religion (optional)
Parent/ Carer 2
Name
*
First Name
Last Name
Date of birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Relationship to child
*
Mother
Father
Carer
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home phone number
-
Area Code
Phone Number
Work phone number
-
Area Code
Phone Number
Mobile phone number
*
Occupation or course of study
Employer or place of study
Business address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
CRN number
*
Email
*
example@example.com
Country of birth
*
Language/s spoken
*
Religion (optional)
Other details
Are there any court orders which relate to your child?
*
Yes
No
(If Yes, please ensure a copy of the relevant court order has been provided to the service. This will be attached to the enrolment record.) Please provide details of arrangements for contact with other parent or carer (if applicable) below:
Other children in family
Rows
Name
Gender
Date of birth
Child 1
Child 2
Child 3
Child 4
Authorisation for others to collect child, and emergency contacts
Please list at least two people authorised to collect your child / at least two people staff can call if you cannot be contacted in an emergency. You may list the same people for both purposes, if you wish. These two contacts must be in addition to your Parent/ Carer information.
Person 1
*
First Name
Last Name
Relationship to child
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home phone number
-
Area Code
Phone Number
Work phone number
-
Area Code
Phone Number
Mobile phone number
Is this person an emergency contact person?
*
Yes
No
Is this person authorised to collect your child?
*
Yes
No
Does this person have your permission to authorise medication?
*
Yes
No
Does this person have your permission to give excursion permission?
*
Yes
No
Person 2
*
First Name
Last Name
Relationship to child
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home phone number
-
Area Code
Phone Number
Work phone number
-
Area Code
Phone Number
Mobile phone number
*
Is this person an emergency contact person?
*
Yes
No
Is this person authorised to collect your child?
*
Yes
No
Does this person have your permission to authorise medication?
*
Yes
No
Does this person have your permission to give excursion permission?
*
Yes
No
Health
Has your child had any serious illnesses in the past?
*
Yes
No
If yes, please provide details
Has your child ever been hospitalised?
*
Yes
No
Please provide details
Does your child currently have a serious illness?
*
Yes
No
Please provide details
Does your child currently have any additional needs or disorder such as Autism Spectrum Disorder (ASD) or Attention Deficit Hyperactivity Disorder (ADHD)?
*
Yes
No
Please provide details
Does your child require any medical procedures/ intervention to be performed on a regular basis?
*
Yes
No
Please provide details
Is your child receiving regular medication?
*
Yes
No
Please provide details
Does the medication have any side effects we need to be aware of?
*
Yes
No
Please provide details
Does your child have Asthma? (If yes, please upload a copy of your child's Asthma Management Plan)
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Does your child have any allergies (including: allergies to sunscreens, antiseptics, etc.)?
*
Yes
No
Please provide details
If yes to the above, is your child’s allergic reaction likely to result in anaphylaxis? Please upload a copy of your child’s Anaphylaxis Action Plan by pressing 'Browse Files' below.
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Does your child have Epilepsy? If yes, please upload a copy of your child’s Epilepsy Management Plan below.
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Child's Medicare number
*
Name of health fund (if applicable)
Child's doctor:
*
Doctor's address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Doctor's phone number
*
-
Area Code
Phone Number
Religious/ cultural requirements in case of accident/injury?
Please upload a copy of your child's immunisation record below. If no record is provided we will need a letter from your GP - otherwise your child will be excluded from SMOOSH if any infectious disease outbreaks occur.
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Fees/ child care subsidy
Who is responsible for the child care fees?
*
First Name
Last Name
Do you wish to receive your account statements via email?
*
Yes
No
Have you or will you apply for the Child Care Subsidy?
*
Yes I am already registered
I will apply
No, I'm not registered and will be paying the full fee
Do you have other NON-school aged children in approved child care services? (Under 5 years, in long day care, family day care etc.)?
*
Yes
No
Information about your child
The information you provide will aid in the preparation of an inclusive program to meet the individual needs of your child. If you require more space, please attach additional information on a separate piece of paper.)
Has your child previously attended a before/after school or vacation care program? If so, please provide details.
Does your child require support to form friendships?
Do you have any concerns about their behaviour (shyness, aggression, etc)?
How does your child show frustration or distress and what methods would you use to calm them?
Please include activities that your child enjoys e.g. music, art and crafts, sports
Does your child have any dislikes, fears and concerns such as crowded situations, loud noises, etc.?
Does your child have any dietary needs or requirements (e.g peanuts, meat products, halal or kosher, etc.)
What languages are spoken at home? (Auslan or others?)
What is their toileting ability and requirements, if any?
Is any personal care assistance required?
What's their level of physical independence - i.e. do they have any limitations to their physical activities?
Is there any other information about your child that would be helpful for staff to know? Such as any religious or cultural beliefs that need to be considered, use of medical aids or equipment?
Permissions
If your child has difficulty breathing while at the service, a staff member with a current First Aid Certificate may administer medication from the service’s Asthma First Aid Kit. Do you agree?
*
Yes
No
If your child has no known allergy but appears to be having an anaphylactic reaction while at the service, the Director/Coordinator will call an ambulance and a staff member with a current First Aid Certificate will follow the recommended treatment from the ambulance staff. This may involve the administration of an epipen from the service’s Anaphylaxis Emergency Kit. Do you agree?
*
Yes
No
Your child’s enrolment at the service will not be accepted unless you agree to the following. I agree that if my child has been injured, or becomes ill while at the service, and if the approved provider Director/ Coordinator/ responsible person at the service thinks it is necessary, he/she will seek: medical treatment for the child from a registered medical practitioner, dental, hospital or ambulance service or transportation of the child by an ambulance service. Do you agree?
*
Yes
No
I give permission for my child to participate in local excursions, short bus trips and outings with SMOOSH staff, either during school term or in vacation care programs.
*
Yes
No
I agree that photographs and videos of my child taken at the service may be used by SECC/ SMOOSH in its publications; on its website and internet; for educational displays; or in presentations at professional development courses and conferences.
*
Yes
No
I understand and accept that I am responsible for paying all fees due to SMOOSH for my child’s attendance, as outlined in the SMOOSH Parent/Carer Handbook.I understand that a $5.00 fee will be charged if the nominated bank account payment is declined. I authorise for my payments to be deducted by South Eastern Community Connect (SECC).
*
Yes
No
Please e-sign below:
Click all that apply:
Please send me the South Eastern Community Connect Families newsletter
Please keep me updated on upcoming courses, programs or services for families in the local community
One last thing! You'll also need to fill our a direct debit form provided by our staff. Please find it below, print it out, and hand it to our staff.
Phew, forms are hard work! Thank you so much for your time.
For further information please feel free to email us at smoosh@secc.sydney or call us on 0431 452 311 or 0431 427 176. Now, press the Submit button below to get your form to us.
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