Coastwide Family Day Care Enrolment Form

Please complete all sections of the Coastwide Family Day Care Enrolment Form, including:

Your Customer Reference Number (CRN) and the CRN for all children enrolling
Your child/children's Medicare Number

Including providing an electronic copy of:

Evidence to confirm your child’s/children ID, which can be either, a copy of their Birth Certificate / Passport / Citizenship Certificate (preferred) or a copy your Medicare card
A copy of the Immunisation History Statement for all children enrolling
A copy of any Health or Asthma Plans if appropriate
A copy of any court orders which may be in place
Electronic copies may be pdf, jpg, gif, png, doc or docx and a maximum size of 1MB each

Parent/Guardian 1 Personal Details *

Full Name *

Phone Contact

Mobile Phone Number

Don't have a mobile phone?

Please tick here and add your preferred contact phone number in the field above, including the area code. Thank you.

Preferred Contact Number *

Address *

Suburb *

Email *

Are you of Aboriginal or Torres Strait Islander descent? *

Are you: *

Parent/Guardian 1 Date of Birth

Date *

Month *

Year *

Employment Status *

Occupation *

Employer/Place of Work *

Family Status? *

Country of birth *

Language spoken at home (More than one option can be selected) * Language spoken at home (More than one option can be selected)

I would like to claim Child Care Subsidy (CCS) for my child/children enrolling with Coastwide Family Day Care *

I acknowledge that I am the Child Care Subsidy (CCS) Claimant. *

To be able to claim your CCS please provide your Customer Reference Number (CRN) *

9 numbers and 1 lowercase letter only "eg:123456789a"

Section

The Full Name of the CCS Claimant is *

The Customer Reference Number (CRN) of the CCS Claimant is *

9 numbers and 1 lowercase letter only "eg:123456789a"

I acknowledge that: *

Parent/Guardian 2 is the CCS Claimant

Parent/Guardian 2 Personal Details:

Parent/Guardian 2 Full Name *

Phone Contact

Mobile Phone Number

Don't have a mobile phone?

Please tick here and add your preferred contact phone number in the field above, including the area code. Thank you.

Preferred Contact Number *

Address *

Suburb *

Email *

Are you of Aboriginal or Torres Strait Islander descent? *

Are you: *

Parent/Guardian 2 Date of Birth

Date *

Month *

Year *

Employment Status *

Occupation *

Employer/Place of Work *

Country of birth *

Language spoken at home (More than one option can be selected) * Language spoken at home (More than one option can be selected)

Family Medical Details

Medical Practitioner or Medical Service

Name *

Address *

Phone Number *

Dental Practice

Name

Phone Number

Child/Children Enrolment Details

I am enrolling child/children *

Child 1 Personal Details & Booked Care

Full Name *

Date of Birth

Date *

Month *

Year *

Gender *

Is your child of Aboriginal or Torres Strait Islander descent? *

Is your child: *

Please provide evidence of your child's id *

Upload *

Maximum upload size: 5MB

Document format: .jpg .gif .png .pdf .doc .docx (max size 5MB)

Your child's CRN *

9 numbers and 1 lowercase letter only "eg:123456789a"

Medical Information

Medicare Number: *

1234/56789/1-1 (the last number relating to the number of your child on the card)

Is your child fully immunised? *

(If no, please provide more information below)

Please provide a copy of their Immunisation History Statement *

Maximum upload size: 5MB

Document format: .jpg .gif .png .pdf .doc .docx (max size 5MB)

Please provide a copy of their Immunisation History Form *

Maximum upload size: 5MB

Document format: .jpg .gif .png .pdf .doc .docx (max size 5MB)

Please provide a copy of their Immunisation Medical Exemption Form *

Maximum upload size: 5MB

Document format: .jpg .gif .png .pdf .doc .docx (max size 5MB)

Does your child have any medical conditions, including asthma, diabetes, epilepsy or a diagnosis that they are at risk of anaphylaxis, or any additional needs, allergies or any disabilities? *

No

Asthma

Diabetes

Diagnosed at risk of Anaphylaxis

Epilepsy

Allergies

Additional Needs

Disability

OtherOther

Do you have a Medical Management, Asthma Action or Anaphylaxis Management Plan? *

Please provide a copy *

Maximum upload size: 5MB

Document format: .jpg .gif .png .pdf .doc .docx (max size 5MB)

Please provide more information about your child's additional needs or disability *

We will be in touch to discuss the additional documentation required prior to your child starting care

Does your child have any cultural or religious needs or requirements? *

Please provide more information *

Does your child have any dietary requirements or intolerances? *

Please provide more information, including any dietary restrictions *

Is your child on any long-term medication? * Is your child on any long-term medication?

Any other information relevant to your child’s enrolment? *

Guardianship, Custody and Parenting Court Orders

Is your child subject to any Guardianship, Custody and Parenting Court orders? *

If Yes - Please provide more information

If Yes - Please provide a copy of this order *

Maximum upload size: 5MB

Document format: .jpg .gif .png .pdf .doc .docx (max size 5MB)

Country of birth *

Language spoken at home (More than one option can be selected) * Language spoken at home (More than one option can be selected)

Please list the days and hours of care agreed with your Educator. For Before and After School Care please list both sessions of care required.

To add more days click the 'Add day' button

Day *

Start Time *

:

End Time *

:

Add Day Clear

Care Requirements

Preferred Start Date *

Please click on field and use calendar to select date

Purpose of care *

I confirm that I am enrolling my child with Coastwide Family Day Care and that my child will be in care with (Please provide the name of the Educator) *

Is this Educator related to the child/children you are enrolling? *

Please indicate if this Preferred Educator is your child/children’s? *

Please use the comment box below to provide more information if needed.

Please confirm the type of child care you require? *

Please indicate if this care will be: *

Routine Excursions

My Educator has confirmed that: *

I confirm that my Educator(s) has discussed their Routine Excursions with me. I have sighted the Risk Assessments and confirm that *

Needing to enrol with a second Educator?

Please tick here

Please list the days and hours of care agreed with your Educator. For Before and After School Care please list both sessions of care required.

To add more days click the 'Add day' button

Day *

Start Time *

:

End Time *

:

Add Remove

Care Requirements

Preferred Start Date *

Please click on field and use calendar to select date

Purpose of care *

I confirm that I am enrolling my child with Coastwide Family Day Care and that my child will be in care with (Please provide the name of the Educator) *

Is this Educator related to the child/children you are enrolling? *

Please indicate if this Preferred Educator is your child/children’s? *

Please use the comment box below to provide more information if needed.

Please confirm the type of child care you require? *

Please indicate if this care will be: *

Routine Excursions

My Educator has confirmed that: *

I confirm that my Educator(s) has discussed their Routine Excursions with me. I have sighted the Risk Assessments and confirm that *

Child 2 Personal Details & Booked Care

Full Name *

Date of Birth

Date *

Month *

Year *

Gender *

Is your child of Aboriginal or Torres Strait Islander descent? *

Is your child: *

Please provide evidence of your child's ID *

Upload *

Maximum upload size: 5MB

Document format: .jpg .gif .png .pdf .doc .docx (max size 5MB)

Your child's CRN *

9 numbers and 1 lowercase letter only "eg:123456789a"

Medical Information

Medicare Number: *

1234/56789/1-1 (the last number relating to the number of your child on the card)

Is your child fully immunised? *

(If no, please provide more information below)

Please provide a copy of their Immunisation History Statement *

Maximum upload size: 5MB

Document format: .jpg .gif .png .pdf .doc .docx (max size 5MB)

Please provide a copy of their Immunisation History Form *

Maximum upload size: 5MB

Document format: .jpg .gif .png .pdf .doc .docx (max size 5MB)

Please provide a copy of their Immunisation Medical Exemption Form *

Maximum upload size: 5MB

Document format: .jpg .gif .png .pdf .doc .docx (max size 5MB)

Does your child have any medical conditions, including asthma, diabetes, epilepsy, or a diagnosis that they are risk of anaphylaxis, or any additional needs, allergies or any disabilities? *

No

Asthma

Diabetes

Diagnosed at risk of Anaphylaxis

Epilepsy

Allergies

Additional Needs

Disability

OtherOther

Do you have a Medical Management, Asthma Action or Anaphylaxis Management Plan? *

Please provide a copy *

Maximum upload size: 5MB

Document format: .jpg .gif .png .pdf .doc .docx (max size 5MB)

We will be in touch to discuss the additional documentation required prior to your child starting care

Please provide more information about your child's additional needs or disability *

Does your child have any cultural or religious needs or requirements? *

Please provide more information *

Does your child have any dietary requirements or intolerances? *

Please provide more information, including any dietary restrictions *

Is your child on any long-term medication? * Is your child on any long-term medication?

Any other information relevant to your child’s enrolment?

Guardianship, Custody and Parenting Court Orders

Is your child subject to any Guardianship, Custody and Parenting Court orders? *

If Yes - Please provide more information

If Yes - Please provide a copy of this order *

Maximum upload size: 5MB

Document format: .jpg .gif .png .pdf .doc .docx (max size 5MB)

Country of birth *

Language spoken at home (More than one option can be selected) * Language spoken at home (More than one option can be selected)

Please list the days and hours of care agreed with your Educator. For Before and After School Care please list both sessions of care required.

To add more days click the 'Add day' button

Day *

Start Time *

:

End Time *

:

Add Day Clear

Care Requirements

Preferred Start Date *

Please click on field and use calendar to select date

Purpose of care *

I confirm that I am enrolling my child with Coastwide Family Day Care and that my child will be in care with (Please provide the name of the Educator) *

Is this Educator related to the child/children you are enrolling? *

Please indicate if this Preferred Educator is your child/children’s? *

Please use the comment box below to provide more information if needed.

Please confirm the type of child care you require? *

Please indicate if this care will be: *

Routine Excursions

My Educator has confirmed that *

I confirm that my Educator(s) has discussed their Routine Excursions with me. I have sighted the Risk Assessments and confirm that’ *

Needing to enrol with a second Educator?

Please tick here

Please list the days and hours of care agreed with your Educator. For Before and After School Care please list both sessions of care required.

To add more days click the 'Add day' button

Day *

Start Time *

:

End Time *

:

Add Remove

Care Requirements

Preferred Start Date *

Please click on field and use calendar to select date

Purpose of care *

I confirm that I am enrolling my child with Coastwide Family Day Care and that my child will be in care with (Please provide the name of the Educator) *

Is this Educator related to the child/children you are enrolling? *

Please indicate if this Preferred Educator is your child/children’s? *

Please use the comment box below to provide more information if needed.

Please confirm the type of child care you require? *

Please indicate if this care will be: *

Routine Excursions

My Educator has confirmed that: *

I confirm that my Educator(s) has discussed their Routine Excursions with me. I have sighted the Risk Assessments and confirm that’ *

Child 3 Personal Details & Booked Care

Full Name *

Date of Birth

Date *

Month *

Year *

Gender *

Is your child of Aboriginal or Torres Strait Islander descent? *

Is your child: *

Please provide evidence of your child's ID *

Upload *

Maximum upload size: 5MB

Document format: .jpg .gif .png .pdf .doc .docx (max size 5MB)

Your child's CRN *

9 numbers and 1 lowercase letter only "eg:123456789a"

Medical Information

Medicare Number: *

1234/56789/1-1 (the last number relating to the number of your child on the card)

Is your child fully immunised? *

(If no, please provide more information below)

Please provide a copy of their Immunisation History Statement *

Maximum upload size: 5MB

Document format: .jpg .gif .png .pdf .doc .docx (max size 5MB)

Please provide a copy of their Immunisation History Form *

Maximum upload size: 5MB

Document format: .jpg .gif .png .pdf .doc .docx (max size 5MB)

Please provide a copy of their Immunisation Medical Exemption Form *

Maximum upload size: 5MB

Document format: .jpg .gif .png .pdf .doc .docx (max size 5MB)

Does your child have any medical conditions, including asthma, diabetes, epilepsy, or a diagnosis that they are risk of anaphylaxis, or any additional needs, allergies or any disabilities? *

No

Asthma

Diabetes

Diagnosed as risk of Anaphylaxis

Epilepsy

Allergies

Additional needs

Disability

OtherOther

Do you have a Medical Management, Asthma Action or Anaphylaxis Management Plan? *

Please provide more information about your child's additional needs or disability *

Please provide a copy *

Maximum upload size: 5MB

Document format: .jpg .gif .png .pdf .doc .docx (max size 5MB)

We will be in touch to discuss the additional documentation required prior to your child starting care

Does your child have any cultural or religious needs or requirements? *

Please provide more information *

Does your child have any dietary requirements or intolerances? *

Please provide more information, including any dietary restrictions *

Is your child on any long-term medication? Is your child on any long-term medication?

Any other information relevant to your child’s enrolment?

Guardianship, Custody and Parenting Court Orders

Is your child subject to any Guardianship, Custody and Parenting Court orders? *

If Yes - Please provide more information

If Yes - Please provide a copy of this order *

Maximum upload size: 5MB

Document format: .jpg .gif .png .pdf .doc .docx (max size 5MB)

Country of birth *

Language spoken at home (More than one option can be selected) * Language spoken at home (More than one option can be selected)

Please list the days and hours of care agreed with your Educator. For Before and After School Care please list both sessions of care required.

To add more days click the 'Add day' button

Day *

Start Time *

:

End Time *

:

Add Day Clear

Care Requirements

Preferred Start Date *

Please click on field and use calendar to select date

Purpose of care *

I confirm that I am enrolling my child with Coastwide Family Day Care and that my child will be in care with (Please provide the name of the Educator) *

Is this Educator related to the child/children you are enrolling? *

Please indicate if this Preferred Educator is your child/children’s? *

Please use the comment box below to provide more information if needed.

Please confirm the type of child care you require? *

Please indicate if this care will be: *

Routine Excursions

My Educator has confirmed that *

I confirm that my Educator(s) has discussed their Routine Excursions with me. I have sighted the Risk Assessments and confirm that *

Needing to enrol with a second Educator?

Please tick here

Please list the days and hours of care agreed with your Educator. For Before and After School Care please list both sessions of care required.

To add more days click the 'Add day' button

Day *

Start Time *

:

End Time *

:

Add Remove

Care Requirements

Preferred Start Date *

Please click on field and use calendar to select date

Purpose of care *

I confirm that I am enrolling my child with Coastwide Family Day Care and that my child will be in care with (Please provide the name of the Educator) *

Is this Educator related to the child/children you are enrolling? *

Please indicate if this Preferred Educator is your child/children’s? *

Please use the comment box below to provide more information if needed.

Please confirm the type of child care you require? *

Please indicate if this care will be: *

Routine Excursions

My Educator has confirmed that: *

I confirm that my Educator(s) has discussed their Routine Excursions with me. I have sighted the Risk Assessments and confirm that *

Child 4 Personal Details & Booked Care

Full Name *

Date of Birth

Date *

Month *

Year *

Gender *

Is your child of Aboriginal or Torres Strait Islander descent? *

Is your child: *

Please provide evidence of your child's ID *

Upload *

Maximum upload size: 5MB

Document format: .jpg .gif .png .pdf .doc .docx (max size 5MB)

Your child's CRN *

9 numbers and 1 lowercase letter only "eg:123456789a"

Medical Information

Medicare Number: *

1234/56789/1-1 (the last number relating to the number of your child on the card)

Is your child fully immunised? *

(If no, please provide more information below)

Please provide a copy of their Immunisation History Statement *

Maximum upload size: 5MB

Document format: .jpg .gif .png .pdf .doc .docx (max size 5MB)

Please provide a copy of their Immunisation History Form *

Maximum upload size: 5MB

Document format: .jpg .gif .png .pdf .doc .docx (max size 5MB)

Please provide a copy of their Immunisation Medical Exemption Form *

Maximum upload size: 5MB

Document format: .jpg .gif .png .pdf .doc .docx (max size 5MB)

Does your child have any additional needs, allergies or intolerances, including any disabilities? *

No

Asthma

Anaphylaxis

Diabetes

Additional needs

Allergies or Intolerances

OtherOther

Do you have an Asthma or Anaphylaxis Plan or Medical Management Plan? *

Please provide a copy *

Maximum upload size: 5MB

Document format: .jpg .gif .png .pdf .doc .docx (max size 5MB)

We will be in touch to discuss the additional documentation required prior to your child starting care

Does your child have any special cultural or religious needs or requirements? *

Please provide more information *

Any other information relevant to your child’s enrolment?

Guardianship, Custody and Parenting Court Orders

Is your child subject to any Guardianship, Custody and Parenting Court orders? *

If Yes - Please provide more information

If Yes - Please provide a copy of this order *

Maximum upload size: 5MB

Document format: .jpg .gif .png .pdf .doc .docx (max size 5MB)

Country of birth *

Language spoken at home (More than one option can be selected) * Language spoken at home (More than one option can be selected)

Please list the days and hours of care agreed with your Educator. For Before and After School Care please list both sessions of care required.

To add more days click the 'Add day' button

Day *

Start Time *

:

End Time *

:

Add Day Clear

Care Requirements

Preferred Start Date *

Please click on field and use calendar to select date

Purpose of care *

I confirm that I am enrolling my child with Coastwide Family Day Care and that my child will be in care with (Please provide the name of the Educator) *

Is this Educator related to the child/children you are enrolling? *

Please indicate if this Preferred Educator is your child/children’s? *

Please use the comment box below to provide more information if needed.

Please confirm the type of child care you require? *

Please indicate if this care will be: *

Routine Excursions

My Educator has confirmed that: *

I confirm that my Educator(s) has discussed their Routine Excursions with me. I have sighted the Risk Assessments and confirm that *

Needing to enrol with a second Educator?

Please tick here

Please list the days and hours of care agreed with your Educator. For Before and After School Care please list both sessions of care required.

To add more days click the 'Add day' button

Days *

Start Time *

:

End Time *

:

Add Remove

Care Requirements

Preferred Start Date *

Please click on field and use calendar to select date

Purpose of care *

I confirm that I am enrolling my child with Coastwide Family Day Care and that my child will be in care with (Please provide the name of the Educator) *

Is this Educator related to the child/children you are enrolling? *

Please indicate if this Preferred Educator is your child/children’s? *

Please use the comment box below to provide more information if needed.

Please confirm the type of child care you require? *

Please indicate if this care will be: *

Routine Excursions

My Educator has confirmed that: *

I confirm that my Educator(s) has discussed their Routine Excursions with me. I have sighted the Risk Assessments and confirm that *

Family Emergency Permissions

To meet our responsibilities in the case of an emergency, incident or illness the Educator or Coordination Unit staff member may seek medical treatment for the child from a registered medical practitioner, hospital or ambulance service, and may access transportation by the ambulance service or other authorised vehicle.

In the case of an emergency you will be contacted as soon as possible.

I hereby confirm that I give my permission. *

Yes

In addition in the case of a fever, the Educator or Coordination Unit staff member may administer paracetamol or ibuprofen. Prior to administering paracetamol or ibuprofen verbal permission will be sought.

Please confirm below: *

Yes, I hereby give permission for paracetamol or ibuprofen

Yes, I hereby give permission for paracetamol only

Yes, I hereby give permission for ibuprofen only

No, I do not give permission

Family Photo Permission

Your Educator or Coordination Unit staff member may take photographs of your child whilst in care.

I give permission for my child to have their photo taken *

I consent to and authorise the use of photos by my Educator as part of a Family Day Care portfolio/observations, which may be shared with other families when in a group photo. *

I consent to and authorise the use of photos by the Coordination Unit as part of a newsletter or on-line article, or any social media activity including Facebook. *

Family Emergency Contacts

Please provide at least two emergency contacts other than Parent/Guardian. Emergency Contacts must be aged 18 years or over.

Emergency Contact 1

Name

Address

Phone Contact

Mobile Phone Number

Don't have a mobile phone?

Please tick here and add your preferred contact phone number in the field above, including the area code. Thank you.

Preferred Contact Number

Email Address

Relationship to child

Authorised to:

More than one option can be selected.

Emergency Contact 2

Name

Address

Phone Contact

Mobile Phone Number

Don't have a mobile phone?

Please tick here and add your preferred contact phone number in the field above, including the area code. Thank you.

Preferred Contact Number

Email Address

Relationship to child

Text

Authorised to:

More than one option can be selected.

Agreement between Parent/Guardian and Coastwide Family Day Care (Complying Written Agreement)

To finalise your enrolment please confirm that you agree to follow the Coastwide Family Day Care Guidelines and Policies as detailed in the Family Handbook and agree to:

1. Pay the enrolment fee in the first week of care
2. Pay the fees according to the Fee Schedule used by the Educator providing the care which I have sighted, read and understood
3. Pay the Parent Levy to the Educator, as per the Educator Fee Schedule. I understand this amount will then be withheld from my CCS if claimed
4. Give required notice of ceasing care in accordance with the conditions of my Educator’s Fee Schedule
5. Notify the Coastwide Family Day Care Office of any changes in care requirements. Changes in circumstances such as phone numbers, place of work, address, custody arrangements, or emergency contacts need to be notified
6. The Educator seeking medical, hospital, ambulance or dental attention in an emergency for my child, the cost of which will be borne by me
7. Authorise Coordination Unit Staff to care for my child/children in an emergency situation
8. Adhere to the parent responsibilities for receiving CCS from the Federal Government
9. Personal information will be shared with authorised persons as required by law or determined if necessary by the Nominated Supervisor
10. Access MyGov to approve my enrolment notification, if claiming CCS
11. Nominate my preferred start date in the enrolment form

All information given on this Enrolment Form is correct at the time of completion *

I hereby acknowledge and agree to the above conditions and confirm that this represents a Complying Written Agreement between myself and Coastwide Family Day Care

Date

I acknowledge that the personal information provided on this form is collected, stored and shared for the purpose of enrolling my child/children with Coastwide Family Day Care (CFDC), an education and care service sponsored by Coastwide Child and Family Services (CCFS). Access to this personal information is limited to CCFS staff and other authorised persons. Supply of personal information is mandatory and non-supply may cause delay or prevent the processing of this request. We acknowledge that personal information collected by CCFS will be used, stored and accessed in accordance with the Commonwealth Privacy Act 1988 - Privacy Amendment 2000. *

Yes I Agree

Your Signature *

Please input your name here to confirm