Enrolment Form - Chabad North Shore

DATES

Please choose the date/s that you would like your child to attend.

Week 1

WEEK 2:

Early Drop-off / Late Pick-up

Please select below if you would like early drop-off, or late pick-up for an additional $5 each.

Early Drop off (8:00am)

Late Pick up (5:00pm)

Total (before Child Care Subsidy - CCS)

$0.00

CHILD INFORMATION

Please fill-in a separate form for each child.

Full Name*

First NameLast Name

Gender*

MaleFemale

Primary Language*

Date of Birth*

DayMonthYear

School Attending*

School Year (2019)*

Child Primarily lives with*

Primary Parent or GuardianSecondary Parent or Guardian

Is the natural mother of the child Jewish?*

YESNO

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

YESNO

PARENTS/GUARDIAN INFORMATION

Primary parent or guardian (as recorded with Centrelink)

Full Name*

First NameLast Name

Relation to child*

E-mail*

Phone (Mobile)*

Phone (Home)

Address*

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

Authorisation*

DETAILS FOR CCS

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

Legal Name of Primary Parent (Registered for CCS)

First NameLast Name

Date of Birth of Primary Parent

DayMonthYear

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

Legal Name of ChildAs registered with Centrelink

First NameLast Name

CRN Number of ChildThis is different to the Primary Parents CRN.

SECONDARY PARENT/GUARDIAN

Full Name*

First NameLast Name

Relation to child*

E-mail*

Phone (Mobile)*

Phone (Home)

Address*

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

Authorisation*

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 NameLast Name

Relation to child*

E-mail*

Phone (Mobile)*

Phone (Home)

Address*

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

Authorisation*

ADDITIONAL/EMERGENCY CONTACT 1

Full Name*

First NameLast Name

Relation to Child*

E-mail*

Phone (Mobile)*

Phone (Home)

Address*

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

Authorisation*

MEDICAL CONTACTS

Please enter your child's Doctors information.

Doctor or Practice Name*

First NameLast Name or practice name

Phone (Work)*

Phone (Mobile)

E-mail

Address*

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

Authorisation*

EmergencyMedical

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*

YESNO

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

YESNO

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

YESNO

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?*

YESNO

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

Does your child have a diagnosed disability?*

YESNO

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: