Enrolment Form – Periwinkle Preschool

SECTION A. YOUR CHILD’S DETAILS

Surname *

Given Names *

Sex *

Female

Male

Date of Birth *

Place of Birth *

Parents Names *

Residential Address: *

Is the postal address the same as above? (If no, please write it below)

Yes

No

Postal Address:

Aboriginal Australian or Torres Strait Islander:

Yes

No

Australian South Sea Islander:

Yes

No

Name and Date of Birth of Siblings:

What language(s) are spoken at home?

Is English your child’s second language?

Yes

No

What cultural/religious background does your child come from? *

Are there any court orders involving your child? If yes, please provide a copy *

Yes

No

Is your child immunised? *

Yes

No

If yes, please provide copy of schedule.
If no, please provide a current certified copy of the child's exemption status.
Please note: New legislative reforms from January 1st, 2016 requires parents to show the current immunisation status of their child or a certified exemption which explains why their child has not been immunised. This information must be presented on the correct ACIR forms. This is a requirement needed to be able to allow the enrolment of children in preschools and child care centres Australia-wide. A copy of these documents must be held on site in the child's file before the child can attend their first day of preschool.

Has your child been diagnosed with a disability, or currently undergoing diagnosis? *

Yes

No

If yes, please detail type of disability, describe how it affects your child, and what management plans are in place.

Does your child have any food allergies/intolerances? *

Yes

No

If yes, please list

Does your child have special dietary requirements? *

Yes

No

Details

Has your child ever had: Diabetes *

Yes

No

Anaphylaxis *

Yes

No

Asthma *

Yes

No

If yes to any of the above, a medical management plan is required from your doctor.

Does your child have any other medical condition(s) or had any surgical procedures that Periwinkle should be aware of? *

Yes

No

If yes, please describe

If yes, has a management plan been provided to the service? *

Yes

No

Is your child on any regular medication? *

Yes

No

If yes, please provide details

What is your child’s Medicare number? Please include ten-digit number, plus the child’s position on the card, plus the expiry date.

Is your child covered under any private health insurance policy? *

Yes

No

Name of Fund:

Member Number:

How was the pregnancy with your child? (eg were you sick?) *

Was your child’s birth: *

Normal

Caesarean

Length of labour:

How long was your child breastfed for?

How long was your child bottle fed for?

What age did your child: Roll Over

Sit Up (unaided):

Crawl:

Walk:

Speak (first words):

Have there been any other significant events in your child’s life that you feel Periwinkle should know about?

Has your child been in any other form of child care before enrolling at Periwinkle? *

Yes

No

Type and No. of days per week:

Will your child attend any other approved care service? *

Yes

No

If so, for how many hours per week and Name of centre:

SECTION B. PARENT/CARER DETAILS & INCOME INFORMATION

Parent/Carer (1)

Name *

Address *

Relationship to the child *

Telephone (home)

Telephone (mobile)

Telephone (work)

Email

Occupation

Work status

Place of work

Health Care Card *

Do you live with the child?

Parent/Carer (2)

Name *

Address *

Relationship to the child *

Telephone (home)

Telephone (mobile)

Telephone (work)

Email

Occupation

Work status

Place of work

Health Care Card *

Do you live with the child?

Are there any step parents/other family members involved in the care of your child?

Do you have any special skills or talents that you could contribute to Periwinkle?

Periwinkle is a parent run preschool. Which of the following would you be interested in?

Joining the management committee – executive position *

Yes

No

Joining the management committee – non - executive position *

Yes

No

Joining the management committee – support role *

Yes

No

Please rank your preferred days being most preferred) for your child to attend Periwinkle.
Please note that your child must attend on consecutive days and preference will be given to
• 4 year olds as per government requirements. (Children who turn 4 on or before the 31st July.)
• Children who are three

Monday, Tuesday & Every Second Wednesday

Thursday & Friday & Every Second Wednesday

Does your family have a Commonwealth Health Benefits Card? *

Yes

No

If yes, provide number:

SECTION C. EMERGENCY CONTACT DETAILS & AUTHORISATIONS TO COLLECT (Other than parents/guardians)
Emergency Contact: Is Someone who can be contacted when we cannot get hold of parents in case of emergency.
Authorisation to collect: Is someone you give permission to collect your child in an emergency and on other occasions. These persons may also be required to give written consent to the Approved Provider or Nominated Supervisor under the circumstances listed below. Personal identification is required from the people listed below to collect your child on your behalf.

Additional Contact 1: Title

First Name

Surname

Relationship to the Child

Phone Numbers: Work / Home

Mobile

Address

Authorised to:

Be an Emergency Contact

Yes

No

Collect Child

Yes

No

Consent for Administration of Medication

Yes

No

Consent to Medical Treatment or Ambulance

Yes

No

Authorise an educator to take the child outside of Periwinkle’s premises

Yes

No

Additional Contact 2: Title

First Name

Surname

Relationship to the Child

Phone Numbers: Work / Home

Mobile

Address

Authorised to:

Be an Emergency Contact

Yes

No

Collect Child

Yes

No

Consent for Administration of Medication

Yes

No

Consent to Medical Treatment or Ambulance

Yes

No

Authorise an educator to take the child outside of Periwinkle’s premises

Yes

No

Your child’s doctor:

Name: *

Address: *

Contact Numbers: (phone) *

Your child’s dentist:

Name: *

Address: *

Contact Numbers: (phone) *

SECTION D. PARENT CONSENT

“I/We agree with the following statements and give consent”

For my/our child to participate in spontaneous excursions such as a walk to the park for lunch;

For my/our child to be filmed and/or photographed by the staff and parents at Periwinkle and for the photo to be used in the school newsletter, on the Periwinkle Preschool website, and/or for the education purpose and promotion of Periwinkle;

For my/our child to be observed by TAFE or university students for the purpose of their studies. I/We are aware that all documentation will remain confidential and only first names or initials will be used;

In the event of illness, accident or emergency, I/we give consent for the staff at Periwinkle to seek and to carry out urgent medical, dental, ambulance service or hospital treatment for my/our child, and or transportation of my child in an ambulance. I/we understand that any costs incurred by this will be at my/our expense;

That I/We have received a copy of the parent handbook and agree to be bound by the procedures and policies therein;

To pay Periwinkle’s invoice promptly on the due date; and

To have my/our e-mail address and telephone number(s) added to the Periwinkle e-mail communication register and the parent/carer phone register. I understand that my/our phone number(s) will be available to all parents as the phone number register is e-mailed to all parents.

I agree to at least one parent/caregiver attending the Periwinkle AGM. This is to ensure a full
Committee of the Parent Management Committee for the year.

“I/We have read and understood the above”

Parent/Carer Signature: *

FIRST AID TREATMENT: Do you agree to staff using antiseptic spray/wipes, Band-aids, etc… from our first aid kit on your child’s minor injuries (grazes etc)? *

Yes

No

Parent/Carer Signature: *

INSECT REPELLENT: Mosquitos can be of great concern in our preschool environment. Do you agree to staff using a natural insect repellent on your child? *

Yes

No

Parent/Carer Signature: *

SUNSCREEN: Families are asked to apply sunscreen to their children before arriving or on arrival at Preschool. Please let staff know if you would like sunscreen reapplied to your child during the day and whether they have their own sunscreen left here. Periwinkle is able to provide a natural sunscreen if you do not have your own. Please confirm whether you agree to staff applying a natural sunscreen to your child? *

Yes

No

Parent/Carer Signature: *

TICK: If staff locate a tick on your child while at preschool, the tick will be removed, and parents/guardians will then be contacted. *

Yes

No

Parent/Carer Signature: *

LAVENDER ESSENTIAL OIL: At Periwinkle we provide the children with a lavender face washer prior to rest time. We use a Dr Hauschka Moor Lavender Calming Bath Essence cream diluted in warm water. This cream can also be applied to mosquito bites to soothe irritation. It is a 100% certified natural product- free from synthetic fragrances, dyes and preservatives. Do you agree to staff using this product for a face washer or for mosquito bites for your child? *

Yes

No

Parent/Carer Signature: *

SPHAGNI ROSE OIL: As part of our program we offer lemon footbaths to the children. To finish a lemon foot-bath it is a lovely gesture to rub a lotion called Sphagni Rose into the child’s feet, giving the child a gentle massage and then placing their socks back on straight after. This is all part of the sensory experience. Sphagni is Peat Moss and plant oil emulsions used externally as a moisturizer which has therapeutic effects on the child and skin. Sphagni Rose compliments the care and protection that a caregiver provides to the child for the development of the senses. If you are happy for your child to receive Sphagni Rose on their skin, please sign the permission form. *

Yes

No

Parent/Carer Signature: *

SECTION E. ACKNOWLEDGEMENTS

Privacy

Periwinkle Preschool at 5 Sunrise Boulevard, Byron Bay understands how important it is to protect your personal information and takes all reasonable steps in order to comply with the Privacy Act in respect to the personal information you provide us with.

The primary purpose of collecting personal information is to enable us to discharge our duty of care to your child. We are required to obtain information about your child to comply with legislation in order to best care for your child.

Once this information is collected it is likely to be found in:

• School reports
• accident/incident forms
• government reporting forms
• financial and billing records
• Parent Committee meeting minutes

This information is collected directly from you or if we need to collect personal information from another person such as a doctor, your consent will be obtained.

Your personal information is carefully secured. The permanent staff at Periwinkle and the three executive members of the Parent Management Committee are the only people who will have access to your child’s records.

Prior to disclosing any of your child’s personal information to another service, health professional or government instrumentality your consent to disclosure will be sought.

It is important that the personal information that we hold about your child is accurate and up to date. We encourage you to inform us of any changes to your child’s personal information as soon as possible.

You may seek access to personal information collected about your child by contacting the Director.

Should you have any complaints about the way Periwinkle manages your child’s personal information you should lodge a complaint through the organisation’s complaints mechanism outlined in the Preschool Parent Handbook.

I have read and understood the privacy acknowledgment. *

Yes

No

Parent Signature: *

Parental Involvement

I understand that Periwinkle is a pre-school fully administered by a parent management committee. I acknowledge that Periwinkle needs some of my time each term to contribute to the running of the preschool. Examples of my contribution could be helping at working bees, fundraising, coming to parent committee meetings, sewing, gardening, helping the staff during the day with tasks or using any of my special skills listed previously to help the Periwinkle community.

I have read and understood the parental involvement *

Yes

No

Parent Signature: *

Name of person completing form (please print): *

Signature: *

Date: *

Please upload Birth Certificate and Immunisation Statement (available from Medicare) *

Maximum upload size: 2.1MB