application





Kent Road Care Centre

Please print out this form, fill in all your details and mail it back to: The Coordinator Kent Road Care Centre Cnr Kent & Herring Rd, Eastwood, NSW 2112

	FOR FAMILIES RE- ENROLLING FOR 2006 (please complete this section if you already use the Centre) Mother Surname: ��... ...First name: �� Address: �� Home ph: ��Work ph: �� Mobile No: ��Customer Reference No: ��...... Father Surname: ��First name: �� Address:��.. Home ph: ��Work ph: �� Mobile No: ��Customer Reference No: ��.. Children 1. Surname: ��First name:�� 2. Surname: ��First name:�� 3. Surname: ��First name:�� Family doctor contact: �� Address: ��.................... Ph: �� * * * FOR FAMILIES ENROLLING FOR THE FIRST TIME IN 2006 Mother Surname: .................................................... First name: .................................................................. Address: ............................................................................................................ P/C ..................... Home ph: (.......) ......................................... Work ph: (.......) .......................................................... Mobile No: (........) ...................................... e-mail: ........................................................................ Customer Reference No: .............................. Father Surname: .................................................... First name: ................................................................. Address: ............................................................................................................ P/C ..................... Home ph: (.......) ......................................... Work ph: (.......) .......................................................... Mobile No: (.......) ....................................... e-mail: ........................................................................ Customer Reference No: .............................. Children 1. Surname: ................................................ First name: .................................................................. Date of birth: ............./..................../....................... 2. Surname: ................................................ First name: .................................................................. Date of birth: ............/..................../........................ 3. Surname: ................................................ First name: .................................................................. Date of birth: ............/..................../........................ Family doctor contact: ..................................................................................................................... Address: ........................................................................................................................................ Phone: (.......) .............................................. Specific issues in helping us care for your child/ren (NOTE: if your child has a disability please contact the coordinator as soon a possible as you are required to complete an additional form which will help us determine whether we can provide the appropriate care) Is there any information you would like staff to be aware of eg cultural background, religious practices, celebrations, languages spoken at home, family circumstances...If yes, please include: ........................... ..................................................................................................................................................... ..................................................................................................................................................... ..................................................................................................................................................... Please complete the following for each individual child: 1. Child�s first name: ............................................... Is your child an asthmatic? Yes / No (please circle) If yes, please outline the treatment: ............................................................................................... ................................................................................................................................................. ................................................................................................................................................. Does your child suffer from any illness, or allergic reactions? Yes / No If yes, please outline the treatment: .............................................................................................. ................................................................................................................................................. ................................................................................................................................................ Does your child have a disability? Yes / No If yes you will need to complete an additional form. Please contact the Coordinator as soon as possible. 2. Child�s first name: ................................................. Is your child an asthmatic? Yes / No If yes, please outline the treatment: ............................................................................................... ................................................................................................................................................. ................................................................................................................................................. Does your child suffer from any illness, or allergic reactions? Yes / No If yes, please outline the treatment: ............................................................................................... ................................................................................................................................................. ................................................................................................................................................. Does your child have a disability? Yes / No If yes you will need to complete an additional form. Please contact the Coordinator as soon as possible. 3. Child�s first name: ................................................ Is your child an asthmatic? Yes / No If yes, please outline the treatment: ............................................................................................... ................................................................................................................................................. ................................................................................................................................................. Does your child suffer from any illness, or allergic reactions? Yes / No If yes, please outline the treatment: ............................................................................................... ................................................................................................................................................. ................................................................................................................................................. Does your child have a disability? Yes / No If yes you will need to complete an additional form. Please contact the Coordinator as soon as possible. Authorisation to collect children and emergency contacts Please list the persons authorised to collect your child/ren from Kent Road Care Centre or who can act on your behalf in case of an emergency. PERSON'S NAME Surname: ..................................................... First name: ................................................................ Relationship to child: ........................................... Contact No. (........) ............................................. PERSON'S NAME Surname: ..................................................... First name: ................................................................ Relationship to child: ..................................... Contact No. (.......) .................................................... PERSON'S NAME Surname: ..................................................... First name: ................................................................ Relationship to child: ..................................... Contact No: (.......) .................................................... Permission for emergency medical care If emergency medical care is required for my child/ren, I hereby authorise the staff to act on my behalf to seek the necessary medical attention. Parent's Signature: ...................................................... Date:. ............./................./................. Permission for photographing, videoing children Like the school, as a way of promoting the Centre and documenting and evaluating the program from time to time the Centre will take pictures and/or video of the children. In addition we hope to provide the means for the children to make their own video movies. I hereby give permission for my child/ren to be photographed and or videoed. Parent's Signature: ....................................................... Date: ............./................./................. I have enclosed the annual $25 registration fee: cash / cheque (please circle) I have enclosed the $75.00 bond: Cash / Cheque Bookings 1. CHILD'S NAME: .............................................................................................. Please tick: O PERMANENT O CASUAL: I will inform the Centre of the days that I need care the day before. Please tick the times your child will permanently attend the Centre: MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY Morning O O O O O Afternoon O O O O O 2. CHILD'S NAME: .............................................................................................. O PERMANENT O CASUAL: I will inform the Centre of the days that I need care the day before. Please tick the times your child will permanently attend the Centre: MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY Morning O O O O O Afternoon O O O O O 3. CHILD'S NAME: ............................................................................................. O PERMANENT O CASUAL: I will inform the Centre of the days that I need care the day before. Please tick the times your child will permanently attend the Centre MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY Morning O O O O O Afternoon O O O O O CCB Notification to Centre According to Family Assistance Office guidelines every family must formally indicate to the Centre how they will claim their CCB benefit. Please tick the option that applies to you: O as a fee reduction (ie you are in the process of submitting the form or awaiting notification from FAO) O as a lump sum claim at the end of the financial year or O do not intend to claim any benefit at all. I have ..............(please insert the number) children in other care Name: ................................................................................. (please print) Signed: ................................................................................ Date: ............../................./............... Please note, if you wish to claim a lump sum you are required to complete the 'request for customer reference number' and return it to the Coordinator as soon as possible. Parent Skills From time to time the centre sometimes requires specialised information or support. If you have a skill that you could offer if needed, for instance, carpenter, accountant, caterer, admin, we�d love to know. If you would like to help, please fill in the slip below and return to the centre. We appreciate how hard parents work and any specialised advise when needed would be great. Thank YOU. What specialised skill/s could you offer if we needed help: Name: ��. Skill: �� Name: ��. Skill: �� About Me Name: ________________________ What is your favourite food? _______________________________ What activities do you like to do? Inside:___________________________________ Outside:_____________________________________ What special things would you like to learn? _________________________________________________ What craft do you like to do? _____________________________________________________________ What craft do you dislike? _______________________________________________________________ What group games do you like to play? _____________________________________________________ If you could learn any sport what would it be? _______________________________________________ What are your hobbies/interests? ___________________________________________________________

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