Vacation Care Enrolment Form

Document Sample
Vacation Care Enrolment Form Powered By Docstoc
					   Vacation Care Enrolment Form
 Please remove Enrolment Form insert from the booklet.

Submit Enrolment Form when booking in person, by fax or post.

      The remainder of the booklet is yours to keep.



   In Person:

            Pittwater Council Customer Services Centres:
            1 Park Street, Mona Vale
            59a Old Barrenjoey Rd, Avalon

   Fax:

            Attention Vacation Care Team on 9970 1197


   Mail:

            Vacation Care Team
            Pittwater Council
            PO Box 882, Mona Vale NSW 1660




            October 2009 Vacation dates:

            Tuesday 6 October to Friday 16 October 2009
                                  Enrolment Form
                                        Page 1 of 5

Parent Details

Parents Name: _______________________________________________________________________


Home Address: ______________________________________________________________________


_____________________________________________________________ Postcode: ____________


Work Ph: _______________________________________ Home Ph: ____________________________


Mobile: _____________________________________________________________________________


Date of Birth: __________________________________Country of Birth: __________________________


Parent Customer Reference Number (CRN): __________________________________________________


Email Address: _______________________________________________________________________


Employer: _______________________________________________Occupation: ___________________


Spouse Details

Parent/Partner Name: __________________________________________________________________


Home Address: _____________________________________________________ (if different from above)


____________________________________________________________ Postcode: ______________


Work Ph: ______________________________________ Home Ph: _____________________________


Mobile: ____________________________________________________________________________


Date of Birth: __________________________________Country of Birth: __________________________


Parent Customer Reference Number (CRN): __________________________________________________


Email Address: _______________________________________________________________________


Employer: _______________________________________________Occupation: ___________________
                                          Enrolment Form
                                                  Page 2 of 5


General

Are there any religious/cultural requirements that need to be observed while your child is at the centre?


___________________________________________________________________________________


___________________________________________________________________________________


Languages spoken at home: ______________________________________________________________


Where do the children normally reside?: _____________________________________________________




Work Status:            2 parent family - both working

                        2 parent family - one working, one not

                        1 parent family - working

                        1 parent family - not working

                        Study

                        Other




Would you be interested in receiving the next Vacation Care Brochure by E-Mail?              Yes         No

   NB: If yes, please check that you have provided this to us on Page 1 of the Enrolment Form under your details.
                                         Enrolment Form
                                                   Page 3 of 5

Emergency Contacts

MUST be available during centre hours (in addition to parents, ie grandparents, aunt, uncle, trusted friend)


                Name                               Contact Phone                           Relationship to Child


1.      _____________________________ __________________________                           ___________________



2.      _____________________________ __________________________                           ___________________



3.      _____________________________ __________________________                           ___________________




Is anyone prohibited from collecting your child?                   Yes         No


Please provide information and attach any relevant Court Orders.


___________________________________________________________________________________

___________________________________________________________________________________


___________________________________________________________________________________



Does your child have any disability or learning problem that may need to be considered by staff?



Please provide information on your child’s needs. Yes      No
___________________________________________________________________________________


___________________________________________________________________________________


___________________________________________________________________________________
                                          Enrolment Form
                                                   Page 4 of 5

Medical Information

Doctor Name: ________________________________________________________________________


Address: ____________________________________________________________________________


Phone: _____________________________________________________________________________


Medicare No: ________________________________________________________________________


Is there any medical or physical condition relating to your child that needs to be brought to the attention of the
centre coordinator ? Please attach further information if more space is required.


__________________________________________________________________________________


Is your child taking any prescribed medications:            Yes         No


Please provide details:


___________________________________________________________________________________


Is your child fully immunised?            Yes         No




Privacy Information: Council is collecting this information for the purpose of registering your child for the Vaca-
tion Care program. The information will be used for administration purposes and to contact you in the event of an
emergency, but will not be disclosed to any other party except as required by law.
                                         Enrolment Form
                                                 Page 5 of 5


If you have children booked on different days – please specify which child will be attending each day.
There are no refunds if you have provided incorrect booking information.


PLEASE CHOOSE YOUR DAYS CAREFULLY. ONCE BOOKED NO CHANGES WILL BE ACCEPTED.


                   Mon                Tues               Wed                 Thurs               Fri

Week 1             Closed             6                  7                 8                  9

Week 2              12                13                 14                15                 16

• $50 per day per child till 5pm Friday 25 September 2009.
• $55 per day per child from after 5pm Friday 25 September 2009.


Children’s Customer Reference Numbers (CRN)


Child 1 CRN ___________________________________________________________



Child 2 CRN ___________________________________________________________



Child 3 CRN ___________________________________________________________



Child 4 CRN ___________________________________________________________



                                                                     Can your
                                                                                                         Country of
 Name of child             Sex         D.O.B.           Class          child            School
                                                                                                           Birth
                                                                      swim?
                                   Enrolment Agreement

1.      I have read the Conditions of Enrolment and agree to abide by these conditions.

2.      In the event of an accident or illness I authorise the obtaining on my behalf of such medical assistance as
        my child/ren may require and agree to meet any expenses attached to this.

3.      I agree to my child going on scheduled excursions with the Vacation Care group on the days that he/she is
        booked into the centre. I agree to my child/ren travelling by bus/ferry/train.

4.      I hereby give permission for my child/ren to leave the centre for walking excursions within the local
        community. I understand notice will be displayed at the centre on the morning of the excursion.

5.      I hereby give permission for sunscreen – Hamilton SPF 30 or similar to be applied to my child/ren in
        accordance with the manufacturers instructions. I will provide a suitable alternative should this sunscreen
        not suit my child. I understand that I am responsible for applying sunscreen each morning prior to my
        child/ren arriving at the centre.

6.      Pittwater Council advises that participation at any level in the Vacation Care program involves recreational
        activities such as sports and games, including swimming at beaches and pools. While Council takes
        measures to make all activities as safe as possible, there are obvious and inherent risks involved. The
        risks may result in property damage or serious injury or in very rare cases the injury can be life threatening
        or result in permanent disability.

7.      I understand that by participating in the Vacation Care program my child may become exposed to the
        risk of injury and I consent to the participation. I have made any further inquiries which I feel are
        necessary or desirable and fully understand the risks involved in the program.

8.      I understand that my child may be excluded from excursions if their behaviour is unacceptable or if
        behaviour guidelines are not adhered to.

I, the signatory acknowledge, agree and understand that participation at any level in events or activities conducted
during the Vacation Care program contains an element of risk of injury. I further agree that the warning noted
above constitutes a “risk warning” for the purposes of Division 5 of the Civil Liability Act 2002 (NSW).


        Parent/Guardian Signature: _______________________________________

Optional Agreement

     •	 I	give	permission	for	photographs	of	my	child/ren	to	be	taken	for	promotional	purposes	only


        Parent/Guardian Signature: ____________________________________


     •	 I	give	permission	for	my	child/ren	to	watch	PG	movies	and	videos		


        Parent/Guardian Signature: ____________________________________
Pittwater Council Office Use Only:


Date received:             ____________________________________________

Time received:             ____________________________


Received by:               Fax         Post                Customer Service


Staff member name:         ____________________________________________


• $50 per day per child till 5pm Friday 25 September 2009.
• $55 per day per child from after 5pm Friday 25 September 2009.


Notes: