CONCESSION /HEALTH CARE CARD HOLDER? PREFERRED METHOD OF CONTACT? PARENT 2 PARENT 2 NAME PARENT 2 SURNAME PARENT 2 DATE OR PARENT 2 CRN: PARENT 2 EMAIL ADDRESS: PARENT 2 GENDER: FORMER NAMES PARENT HAS BEEN KNOWN BY ADDRESS: SUBURB: POSTCODE: PLACE OF BIRTH HOME PHONE WORK NUMBER MOBILE NUMBER LANGUAGE SPOKEN AT HOME OCCUPATION PLACE OF WORK: WORK STARTS: WORK FINISHES CONCESSION /HEALTH CARE CARD HOLDER? PREFERRED METHOD OF CONTACT? FAMILY STATUS (Please circle) BOTH PARENTS AT HOME SOLE PARENT SHARED CARED OTHER ADDITIONAL DETAILS: CUSTODY ARRANGEMENTS If separated or divorced, who has legal custody of the child? (Please circle) Parent One Parent Two Both Parent 1 Access Arrangements? □ Full □ Limited Parent 2 Access Arrangements? □ Full □ Limited Are there any court orders, parent order or parenting plans relating to the powers and responsibilities of the parents in relation to the child or access to the child? (If Yes, please provide these details) □ Yes □ No Is anyone who is prohibited from having contact with the child? (If yes, please provide details). □ Yes □ No EMERGENCY CONTACTS AND AUTHORISATION Contact 1 FIRST NAME SURNAME RELATIONSHIP TO ADDRESS:
Dentist Name: Phone Number: Dentist Address: Private Health: □ Yes □ No Provider and Membership No. Ambulance Subscription □ Yes □ No Do you provide authorisation for the child to self-administer medication? □ Yes □ No Do you give consent for the service to seek medical treatment for the child from a registered medical practitioner, hospital or ambulance service? □ Yes □ No Do you give consent for the service to seek transportation of the child by an ambulance service? □ Yes □ No Has your child been diagnosed at risk of Anaphylaxis □ Yes □ No If yes, to what? (Please provide medical management plan) Does your child have any allergies? e.g. food, medication, animals insects? □ Yes □ No If yes, to what? (Please provide medical management plan if applicable) Does your child have any special dietary requirements? □ Yes □ No If yes, please explain Does your child have any problems with hearing, sight, speech? □ Yes □ No If yes, please explain Does your have any health problems, operations, illnesses, disabilities? □ Yes □ No If yes, please explain (Please provide medical management plan if applicable), Does your child have asthma? □ Yes □ No If yes - (Please provide medical management plan) Does your child take any regular medication? □ Yes □ No If yes – please explain Does your child have a physical disability or delay, including intellectual, sensory or physical impairment? □ Yes □ No If yes – please explain. (Please provide medical management plan if applicable) Does either parent have a disability? □ Yes □ No Is the family a single parent family? □ Yes □ No Please provide further information to the above medical questions if applicable. IF YOU HAVE INDICATED A MEDICAL CONDITION ABOVE PLEASE ENSURE THAT YOU HAVE COMPLETED A MEDICAL MANAGEMENT PLAN WITH THIS ENROLMENT. ROUTINES Has your begun toilet training? □ Yes □ No Is your child used to being with other children? □ Yes □ No Is your child used to being with other adults? □ Yes □ No Is this the first time your child has been cared for by someone other than a family member? □ Yes □ No Are there any aspects of your child’s cultural, ethnic, and/or religious background □ Yes □ No Are there any special considerations for your child? Eg. cultural, religious or additional needs? □ Yes □ No