OSHC Enrolment Form

- Step 1 of 3

CHILD

Student Name *

First

Last

Known As

CRN

Date of Birth *

Gender *

• Male
• Female

Primary Residential Address *

Address Line 1

City

State / Province / Region

Postal Code

Primary Language

Aboriginal

• Yes
• No

Torres Strait Islander

• Yes
• No

ELIGIBLE PARENT/GUARDIAN & BILLING DETAILS

Parent/Guardian Name *

First

Last

Parent/Guardian Date of Birth *

Parent/Guardian CRN

Relationship to Child

Parent/Guardian Address *

Address Line 1

City

State / Province / Region

Postal Code

Layout

Parent/Guardian Phone

Parent/Guardian Mobile

Parent/Guardian Work Number

Email Address *

OTHER PARENT/GUARDIAN

Other Parent/Guardian Name

First

Last

Other Parent/Guardian Relationship to Child

Other Parent/Guardian Address

Address Line 1

City

State / Province / Region

Postal Code

Layout (copy)

Other Parent/Guardian Phone

Other Parent/Guardian Mobile

Other Parent/Guardian Work Number

Other Parent/Guardian Email Address

Parenting Plans/Orders relating to this child

EMERGENCY CONTACTS & COLLECTION AUTHORITIES

Emergency Contact #1 *

Emergency Contact #1 Address *

Address Line 1

City

State / Province / Region

Postal Code

Emergency Contact #1 Relationship to Child

Layout (copy) (copy)

Emergency Contact #1 Phone

Emergency Contact #1 Mobile

Emergency Contact #1 Work Number

Emergency Contact #2

Emergency Contact #2 Address

Address Line 1

City

State / Province / Region

Postal Code

Emergency Contact #2 Relationship to Child

Layout (copy) (copy) (copy)

Emergency Contact #2 Phone

Emergency Contact #2 Mobile

Emergency Contact #2 Work Number

COLLECTION AUTHORITIES ONLY

N.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 #1

Collection Authority #1 Address

Address Line 1

City

State / Province / Region

Postal Code

Collection Authority #1 Relationship to Child

Layout (copy) (copy) (copy) (copy)

Collection Authority #1 Phone

Collection Authority #1 Mobile

Collection Authority #1 Work Number

Collection Authority Name #2

Collection Authority #2 Address

Address Line 1

City

State / Province / Region

Postal Code

Collection Authority #2 Relationship to Child

Layout (copy) (copy) (copy) (copy) (copy)

Collection Authority #2 Phone

Collection Authority #2 Mobile

Collection Authority #2 Work Number

Next

MEDICAL AND HEALTH INFORMATION

Has the child received all immunisations appropriate for their age? *

• Yes
• No

If no, please give details:

• I accept full responsibility if my child is not immunised.

Has the child received the following immunisations? (12 - 13 years)

• Diphtheria
• Tetanus
• Pertussis (Whooping Cough)
• Human Papillomavirus (HPV)

Has the child any conditions / medications that may be effected by OSHC activities? *

• Yes
• No

If yes, please give specifics and any related medication:

Has the child any disabilities? *

• Yes
• No

Effective date:

If yes, please record specifics:

Has the child any special needs? *

• Yes
• No

Effective date:

If yes, please record specifics:

Does 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 details

Foods:

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 attendant

Layout

Doctor's name:

Phone No.:

Clinic name:

Address:

Usual Dental attendant

Layout (copy)

Dentist's name:

Phone No.:

Clinic name:

Address:

Medical Benefits cover with:

Ambulance cover with:

Medicare number:

Health Care Card number:

Is there anything more we need to know? (copy)

(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.)

Next

CONSENTS

Consents

• 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 that the staff of the Service may administer simple first aid to my child if the need arises.

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.

Signature

Clear Signature

Submit