Enrolment Form - Chabad North Shore

DATES
Please choose the date/s that you would like your child to attend.
Entire Week 1: 13-17 July 2020Monday, 13 JulyTuesday, 14 JulyWednesday, 15 JulyThursday, 16 JulyFriday, 17 July
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 per day.
Early Drop off (8:00am)
Monday, 13 JulyTuesday, 14 JulyWednesday, 15 JulyThursday, 16 JulyFriday, 17 July
Late Pick up (5:00pm)
Monday, 13 JulyTuesday, 14 JulyWednesday, 15 JulyThursday, 16 JulyFriday, 17 July
THE TOTAL EXCLUDES CCS SUBSIDY (IF ELIGIBLE)
Total
$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*
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*
CollectionExcursionEmergencyMedicalAllow Sign In / OutAllow Confirm In / Out
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*
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 unavailable to be contacted in the case of an emergency. E.g for medical authorisations, to authorise staff to remove the child form the facility or for any other emergencies. This may also include authorised nominees who may drop off or pick up this child or authorise excursions.
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 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
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
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 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
We needs to sight the child's immunisation history statement. Please email chanie@chabadhouse.org.au with your child’s Medicare immunisation form (or bring a copy into the office for us to sight).
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 authorise Camp Gan Izzy to take the above child on the excursions that are on the days I have enrolled them based on the this excursion list here.
·  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 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:
Should be Empty:

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