Gan Izzy Extreme Enrolment Form - Chabad North Shore

PROGRAM

Who: Boys Years 6-9 and Girls years 6-8 (separate programs)
Where : Chabad North Shore, 27 College Cr, St Ives.
When : Wednesday 8 January 2020 8:30am - Friday 10 January 2020 2:00pm.
Cost : $150 (includes trips & food).

Please Chose A Program

CHILD INFORMATION

Please fill-in a separate form for each child.

Full Name*

First Name Last Name

Date of Birth*

Day Month Year

Gender*

Male Female

School Attending*

School Year (2019)*

Child Primarily lives with*

Primary Parent or Guardian Secondary Parent or Guardian

Is the natural mother of the child Jewish?*

YES NO

Have there been any conversions or adoptions in the family?*

YES NO

PARENTS/GUARDIAN INFORMATION

Primary parent or guardian (as recorded with Centrelink)

Full Name*

First Name Last Name

Relation to child*

E-mail*

Phone (Mobile)*

Phone (Home)

Address*

Street Address
Street Address Line 2
Suburb	State / Territory
Post Code	Country

Authorisation*

Collection Excursion Emergency Medical Allow Sign In / Out Allow Confirm In / Out

DETAILS FOR CCS

This information must be complete in order to receive CCS (Child Care Subsidy).

This is all dependant on eligibility, if your child is in year 7+ they will be uneligible for CCS.

Legal Name of Primary Parent (Registered for CCS)

First Name Last Name

Date of Birth of Primary Parent

Day Month Year

CRN Number of Primary Parent This is different to the child's CRN.

Legal Name of Child As registered with Centrelink

First Name Last Name

CRN Number of Child This is different to the Primary Parents CRN.

SECONDARY PARENT/GUARDIAN

Full Name*

First Name Last Name

Relation to child*

E-mail*

Phone (Mobile)*

Phone (Home)

Address*

Street Address
Street Address Line 2
Suburb	State / Territory
Post Code	Country

Authorisation*

Collection Excursion Emergency Medical Allow Sign In / Out Allow Confirm In / Out

ADDITIONAL/EMERGENCY CONTACTS

(Minimum 2 required)

Please enter additional contacts for this child's enrolment. This may include emergency contacts when you are not available to be contacted or authorised nominees who may drop off or pick up this child.

ADDITIONAL/EMERGENCY CONTACT 1

Full Name*

First Name Last Name

Relation to child*

E-mail*

Phone (Mobile)*

Phone (Home)

Address*

Street Address
Street Address Line 2
Suburb	State / Territory
Post Code	Country

Authorisation*

Collection Excursion Emergency Medical Allow Sign In / Out Allow Confirm In / Out

ADDITIONAL/EMERGENCY CONTACT 1

Full Name*

First Name Last Name

Relation to Child*

E-mail*

Phone (Mobile)*

Phone (Home)

Address*

Street Address
Street Address Line 2
Suburb	State / Territory
Post Code	Country

Authorisation*

Collection Excursion Emergency Medical Allow Sign In / Out Allow Confirm In / Out

MEDICAL CONTACTS

Please enter your child's Doctors information.

Doctor or Practice Name*

First Name Last Name or practice name

Phone (Work)*

Phone (Mobile)

E-mail

Address*

Street Address
Street Address Line 2
Suburb	State / Territory
Post Code	Country

Authorisation*

Emergency Medical

AUTHRISATION

I agree that if my child has been injured, or becomes ill whilst at the service or otherwise in care, for the approved provider, a nominated supervisor or an educator to seek: Medical treatment for the child from a registered medical practitioner, hospital or ambulance service and transportation of the child by an ambulance service*

YES NO

I give consent to the carrying out of appropriate medical, dental or hospital treatment*

YES NO

Does your child have any special considerations we need to take into account for their enrolment?*

YES NO

If Yes to the previous question, please advise of the special considerations.

MEDICAL CONDITION AND/OR DIETARY RESTRICTION

Does your child have any medical management plan, anaphylaxis medical management plan or risk minimisation plan with respect to the child's healthcare need, medical condition or allergy?*

YES NO

If yes, you MUST email a colour copy of your child’s Action Plan to chanie@chabadhouse.org.au and ensure they bring their medication on each day.

Does your child have a diagnosed disability?*

YES NO

If Yes to previous question, please advise of the diagnosed disability.

IMMUNISATIONS

In order to qualify for CCS, we needs to sight the child's immunisation history statement. Please email chanie@chabadhouse.org.au with your child’s Medicare immunisation form.

ADDITIONAL INFORMATION

Please provide any information you feel the service should know about the child e.g. language, religion, additional needs etc.

CCS ENROLMENT AGREEMENT

As a part of your enrolment at our service (Camp Gan Izzy) we require you to confirm acceptance of the following items in order to be eligible to receive Government funding if available. Acceptance of these items as well as some of the other information in the enrolment form can be used as a Complying Written Arrangement. Please read these items and confirm your acceptance of these items, by signing below.

· I confirm that my details in this enrolment form as well as the details of the child I am enrolling are correct.

· I confirm I have agreed to days of care with this service and understand the start and end times of the care provided.

· I confirm that care may be provided on a casual or flexible basis where available at my service(s) at my request.

· I confirm I understand the usual fees associated with the care of my child which may vary from time to time.

CAMP GAN IZZY ENROLMENT AGREEMENT

By signing below, I confirm,

· I indemnify Chabad North Shore against responsibility for any accident, loss or injury suffered by my child/ren during the course of the activities.

· I expressly release Chabad North Shore, its employees or officers from any claim or liability arising directly or indirectly from the enrolled program.

· I agree to the terms and conditions listed here .

· I understand that my child will be photographed and videoed for the purposes of recording the wonderful services we offer, and sharing this information with our parent-body, and for encouraging the attendance of others within our community. (If you specifically do not want pictures of video clips of your child/ren shared, please contact Chanie Schapiro to discuss.)

Sign by filling-in your full Legal Name*

PAYMENT INFORMATION

Please note: All bookings are final and there are no refunds for cancellations. For more information please see terms and conditions.

IMPORTANT NOTE RE: CCS (CHILD CARE SUBSIDY)

All payment will be processed upon completion of the enrolment form.

If you are a new applicant and have not yet confirmed CCS, we will charge you 50% upon completion of the form and will charge the balance on two weeks prior to commencement of the camp session (to give you time to apply for CCS).

If you are approved for CCS at a later date, and the subsidy is paid to Camp Gan Izzy, you will be reimbursed the difference.

Click here for the rates.

Click here for more information about CCS.

Payment*

Credit Card Direct Debit

The information below should only be completed if you selected Direct Debit.

Bank:

Account Name:

BSB:

Account Number: