Enrolment Form

Enrolment Form
Sex *
Is the postal address the same as above? (If no, please write it below)
Aboriginal Australian or Torres Strait Islander:
Australian South Sea Islander:
Is English your child’s second language?
Are there any court orders involving your child? If yes, please provide a copy *
Is your child immunised? *
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? *
Does your child have any food allergies/intolerances? *
Does your child have special dietary requirements? *
Has your child ever had: Diabetes *
Anaphylaxis *
Asthma *
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? *
If yes, has a management plan been provided to the service? *
Is your child on any regular medication? *
Is your child covered under any private health insurance policy? *
Was your child’s birth: *
Has your child been in any other form of child care before enrolling at Periwinkle? *
Will your child attend any other approved care service? *
Parent/Carer (1)
Parent/Carer (2)
Periwinkle relies on parent involvement as an essential part of the operation of the preschool and the fulfilment of the aims and objectives of the centre.

In addition to attending Working Bees (once per term) and participating in Parent Curriculum Nights, one parent per family is expected to contribute their skills and talents through committing to either an Executive Committee Role, A Coordinator, or a Support Role. In anticipation of filling these roles, please complete and return this questionnaire.

Please indicate your areas of interest and expertise (tick any that apply):
Please indicate your preference on taking on a Executive Committee Role, A Coordinator or a Committee Support Role? Please select one or more: *
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 are three (who will turn 4 on or before the 31st July.)
Does your family have a Commonwealth Benefits Health Care Card? *
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.
Authorised to:
Be an Emergency Contact
Collect Child
Consent for Administration of Medication
Consent to Medical Treatment or Ambulance
Authorise an educator to take the child outside of Periwinkle’s premises
Authorised to:
Be an Emergency Contact
Collect Child
Consent for Administration of Medication
Consent to Medical Treatment or Ambulance
Authorise an educator to take the child outside of Periwinkle’s premises
Your child’s doctor:
Your child’s dentist:
“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”

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)? *
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? *
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? *
TICK: If staff locate a tick on your child while at preschool, the tick will be removed, and parents/guardians will then be contacted. *
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? *
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. *
Periwinkle Preschool Inc.
NSW Incorporated Association Number: Y1050315
ABN: 85 415 680 122

As part of the Periwinkle Preschool enrolment process, you will be charged a $5 membership fee to become a member of the Periwinkle Association.

Membership of the Association gives parents and caregivers the right to vote at Management Committee meetings and all families are encouraged to join the Association as part of the preschool’s community ethos. Please advise if you do not wish to become a member of the Association.

Please note:
1. Membership is not transferable
2. Once approved, only the above signed is a member of Periwinkle Preschool Inc.
3. Initial membership is $5 for 2 years, & subsequent to the initial 2 years is renewable each year at $2 per year.

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. *
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 *
Please upload Birth Certificate and Immunisation Statement (available from Medicare) *
Maximum upload size: 2.1MB