Enrolment Form - Chabad North Shore

DATES
Please choose the date/s that you would like your child to attend.
WEEK 1. 8-12 JULY 2019
Entire WeekMonday, 8 JulyTuesday, 9 JulyWednesday, 10 JulyThursday, 11 JulyFriday, 12 July
WEEK 2. 15-19 JULY 2019
Entire WeekMonday, 15 JulyTuesday, 16 JulyWednesday, 17 JulyThursday, 18 JulyFriday, 19 July
Total (before Child Care Subsidy - CCS)
$0.00 AUD
CHILD INFORMATION
Seperate form required for each child.
Full Name*
First NameLast Name
Gender*
MaleFemale
Hebrew Name*
Primary Language*
Date of Birth*
DayMonthYear
School Attending*
School Year (2019)*
Child Primarily lives with*
Primary Parent/GuardianSecondary Parent/Guardian
Is the natural mother of the child Jewish?*
YESNO
Have there been any conversions or adoptions in the family?*
YESNO
PARENTS/GUARDIAN DETAILS

PRIMARY 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*
CollectionExcursionEmergencyMedicalAllow Sign In / OutAllow Confirm In / Out
CHILD CARE SUBSIDY (CCS) DETAILS
This information must be completed entirely to receive Cenrelink subsidies.
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*
CollectionExcursionEmergencyMedicalAllow Sign In / OutAllow 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 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*
CollectionExcursionEmergencyMedicalAllow Sign In / OutAllow Confirm In / Out
ADDITIONAL/EMERGENCY CONTACT 2
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*
CollectionExcursionEmergencyMedicalAllow Sign In / OutAllow Confirm In / Out
MEDICAL CONTACTS
Please enter your child's Doctors information.
Doctor or Practice Name*
First NameLast Name or practice name
Relation to child*
E-mail
Phone (Work)*
Phone (Mobile)

Address*

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

Authorisation*
EmergencyMedical
AUTHORISATION
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, please advise of the special considerations.
MEDICAL CONDITION & 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 to chanie@chabadhouse.org.au and ensure they bring their medication on each day.
Does your child have a diagnosed disability?*
YESNO
If Yes, please advise of the diagnosed disability.
IMMUNISATIONS
The service 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.
Child Care Subsidy (CCS) Enrolment Agreement
As a part of your enrolment at our service 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 House of the North Shore Limited (CHOTNS) against responsibility for any accident, loss or injury suffered by my child/ren during the course of the activities.
I expressly release CHOTNS, its employees or officers from any claim or liability arising directly or indirectly from the enrolled program.
I agree to all the terms and conditions listed here.
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 Legal Name*
PAYMENT
If no Centrelink information is submitted, the full amount will be processed upon submission.
For details about CCS, please contact Chanie Schapiro ( chanie@chabadhouse.org.au ).
REGISTERED FOR CCS
Once this form is submitted, we will send this information to Centrelink, following this families registered previously for CCS will have to 'confirm' this booking with Centrelink to recieve the subsidy (via my.gov.au ).
We will charge 20% upon submission of this form.
The balance will be charged 48 hours after we have sumbitted your information to Centrelink. This allows you time to confirm your booking (with Centrelink via my.gov.au ).

Payment*

Credit Card Direct Debit

The information below should only be completed if you selected Direct Debit.
Financial Institution:
Account Name:
BSB:
Account Number:
See top of page for errors, if this form does not submit.
Should be Empty: