OSHC Enrolment Form Henley Beach Primary School $ OSHC Enrolment Form Please enable JavaScript in your browser to complete this form. - Step 1 of 3Student Name *FirstLastKnown AsCRNDate of Birth *Gender *MaleFemalePrimary Residential Address *Address Line 1Address Line 2CityState / Province / RegionPostal CodePrimary Language AboriginalYesNoTorres Strait IslanderYesNoEligible Parent/Guardian & Billing DetailsParent / Guardian Name *FirstLastParent / Guardian CRN *Relationship to Child *Parent / Guardian Address *Address Line 1Address Line 2CityState / Province / RegionPostal CodeParent / Guardian PhoneParent / Guardian MobileParent / Guardian Work NumberEmail Address *Other Parent / GuardianOther Parent / Guardian NameFirstLastOther Parent / Guardian Relationship to ChildOther Parent / Guardian AddressAddress Line 1Address Line 2CityState / Province / RegionPostal CodeOther Parent / Guardian Phone Other Parent / Guardian MobileOther Parent / Guardian Work NumberOther Parent / Guardian Work Email AddressParenting Plans / Orders Relating to This ChildEmergency Contacts & Collection AuthoritiesEmergency Contact #1 *Emergency Contact #1 Address *Address Line 1Address Line 2CityState / Province / RegionPostal CodeEmergency Contact #1 Relationship to ChildEmergency Contact #1 PhoneEmergency Contact #1 MobileEmergency Contact #1 Work NumberEmergency Contact #2Emergency Contact #2 Address Address Line 1Address Line 2CityState / Province / RegionPostal CodeEmergency Contact #2 Relationship to Child Emergency Contact #2 Phone Emergency Contact #2 Mobile Emergency Contact #2 Work Number Collection Authorities OnlyN.B. The people nominated here have been given approval only to collect the child and should NOT be contacted in case of an emergency.Collection Authority Name #1Collection Authority #1 AddressAddress Line 1Address Line 2CityState / Province / RegionPostal CodeCollection Authority #1 Relationship to ChildCollection Authority #1 PhoneCollection Authority #1 MobileCollection Authority #1 Work NumberCollection Authority Name #2Collection Authority Name #2Address Line 1Address Line 2CityState / Province / RegionPostal CodeCollection Authority #2 Relationship to ChildCollection Authority #2 PhoneCollection Authority #2 MobileCollection Authority #2 Work NumberNextMedical and Health InformationHas the child received all immunisations appropriate for their age? *YesNoI accept full responsibility if my child is not immunised.YesHas the child received the following immunisations? (12 - 13 years)DiphtheriaTetanusPertussis (Whooping Cough)Human Papillomavirus (HPV)Has the child any conditions / medications that may be effected by OSHC activities? *YesNoHas the child any disabilities? *YesNoHas the child any special needs? *YesNoDoes the child usually require special aids (e.g. glasses, hearing aid etc.)?Has the child any special dietary needs not related to allergies?Has the child suffered any illness that may re-occur (e.g. chronic ear infection)?Has the child had any kind of allergic reactions or food intolerances?Include any Reaction / Medication detailsFoods:Penicillin:Others:Is there any other medical information we might need to know?Note: Please supply the service with required medications in original containers with the child's name clearly marked. Please complete a permission to administer medication form together with any medication records where necessary.Usual Medical AttendantDoctor's name:Clinic name:Phone No.:Address:Usual Dental AttendantUsual Dental Attendant (copy)Dentist's name:Clinic name:Phone No.:Address:Medical Benefits cover with:Ambulance cover with:Medicare number:Health Care Card number:Is there anything more we need to know? (e.g. 1. any personal, religious or cultural practices/prohibitions that you would like the service to know or 2. comments on homework, behaviour management etc.)NextConsents *I consent for my child to watch movies or play games with a G or PG rating. ( SHREK)/ (SINGSTAR).I give consent for my child's name to be used on school platforms (newsletter, website).I consent for my child to take part in excursions organised by the Service.I consent for my child to be photographed and published to school platforms in circumstances the Director deems to be appropriate.I consent for Centre staff to apply sunblock to my child if required.I consent for Centre staff to apply insect repellent to my child if required.I give consent for my child to be taken by a staff member to the local hospital or doctor's surgery in the event of a minor injury.Agreements *I agree to pay the required fees for my child's booked childcare hours and accept the policies and rules of the Service.I agree to pay the required fees for my child's booked childcare hours and accept the policies and rules of the Service.I understand that if at any time the staff of the Service consider that my child requires emergency medical/hospital/ambulance assistance, they will have the local medical/ hospital/ambulance attend my child. I acknowledge that I will be liable for any medical/ hospital/ambulance expenses incurred in the treatment of my child.I certify that the information entered upon this form is true to the best of my knowledge and I undertake to inform the Service if any of these details change.SignatureSubmit
