Enrolment Form - ChabadHouse.org.au

CHILD 1
If your child has attended Camp Gan Izzy or Chabad Hebrew School since 2019, you can register via "Returning Child Enrolment Form."

For a full list of rates click here.

Capacity is limited. Your spot will be confirmed within 2 business days of booking.
How many children would you like to enrol*
Week 1 - Dates Attending Child 1 .

Entire Week 1: 8-12 January 2024Monday, 8 January 2024Tuesday, 9 January 2024Wednesday, 10 January 2024Thursday, 11 January 2024Friday, 12 January 2024
Week 2 - Dates Attending Child 1 .

Entire Week 2: 15-19 January 2024Monday, 15 January 2024Tuesday, 16 January 2024Wednesday, 17 January 2024Thursday, 18 January 2024Friday, 19 January 2024
Early Drop-off / Late Pick-up

Please select below if you would like early drop-off or late pick-up for an additional $7.50 each per day.
Early Drop-off (8:00 am) Child 1 .

Monday, 8 January 2024Tuesday, 9 January 2024Wednesday, 10 January 2024Thursday, 11 January 2024Friday, 12 January 2024Monday, 15 January 2024Tuesday, 16 January 2024Wednesday, 17 January 2024Thursday, 18 January 2024Friday, 19 January 2024
Late Pick-up (5:00 pm) Child 1 .

Monday, 8 January 2024Tuesday, 9 January 2024Wednesday, 10 January 2024Thursday, 11 January 2024Monday, 15 January 2024Tuesday, 16 January 2024Wednesday, 17 January 2024Thursday, 18 January 2024
CHILD INFORMATION
Child's Full Name* Child 1 .

First Name Last Name
Gender*

MaleFemale
Date of Birth*

Day Month Year
School Attending*
School Year (2024)*
Primary Language
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
CCS (Child Care Subsidy) Details

This is required to receive government subsidies.
Full Legal Name of Child* Child 1 .

First Name Last Name
CRN Number* Child 1 .
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 [email protected] and ensure they bring their medication on each day they attend.
Does your child have a diagnosed disability?*

YESNO
If Yes, please advise of the diagnosed disability.
ADDITIONAL INFORMATION
Please provide any information you feel the service should know about the child e.g. language, religion, court orders, additional needs etc.
CHILD 2
Week 1 - Dates Attending Child 2

Entire Week 1: 8-12 January 2024Monday, 8 January 2024Tuesday, 9 January 2024Wednesday, 10 January 2024Thursday, 11 January 2024Friday, 12 January 2024
Week 2 - Dates Attending Child 2

Entire Week 2: 15-19 January 2024Monday, 15 January 2024Tuesday, 16 January 2024Wednesday, 17 January 2024Thursday, 18 January 2024Friday, 19 January 2024
Early Drop-off / Late Pick-up

Please select below if you would like early drop-off or late pick-up for an additional $7.50 each per day.
Early Drop-off (8:00 am) Child 2 .

Monday, 8 January 2024Tuesday, 9 January 2024Wednesday, 10 January 2024Thursday, 11 January 2024Friday, 12 January 2024Monday, 15 January 2024Tuesday, 16 January 2024Wednesday, 17 January 2024Thursday, 18 January 2024Friday, 19 January 2024
Late Pick-up (5:00 pm) Child 2 .

Monday, 8 January 2024Tuesday, 9 January 2024Wednesday, 10 January 2024Thursday, 11 January 2024Monday, 15 January 2024Tuesday, 16 January 2024Wednesday, 17 January 2024Thursday, 18 January 2024
CHILD INFORMATION
Full Name* Child 2 .

First Name Last Name
Gender*

MaleFemale
Primary Language
Date of Birth*

Day Month Year
School Attending*
School Year (2024)*
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
CCS (Child Care Subsidy) Details

This is required to receive government subsidies.
Full Legal Name of Child*

First Name Last Name
CRN Number*
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 [email protected] 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.
ADDITIONAL INFORMATION
Please provide any information you feel the service should know about the child e.g. language, religion, court orders, additional needs etc.
CHILD 3
Week 1 - Dates Attending Child 3 .

Entire Week 1: 8-12 January 2024Monday, 8 January 2024Tuesday, 9 January 2024Wednesday, 10 January 2024Thursday, 11 January 2024Friday, 12 January 2024
Week 2 - Dates Attending Child 3 .

Entire Week 2: 15-19 January 2024Monday, 15 January 2024Tuesday, 16 January 2024Wednesday, 17 January 2024Thursday, 18 January 2024Friday, 19 January 2024
Early Drop-off / Late Pick-up

Please select below if you would like early drop-off or late pick-up for an additional $7.50 each per day.
Early Drop-off (8:00am) Child 3 .

Monday, 8 January 2024Tuesday, 9 January 2024Wednesday, 10 January 2024Thursday, 11 January 2024Friday, 12 January 2024Monday, 15 January 2024Tuesday, 16 January 2024Wednesday, 17 January 2024Thursday, 18 January 2024Friday, 19 January 2024
Late Pick-up (5:00pm) Child 3 .

Monday, 8 January 2024Tuesday, 9 January 2024Wednesday, 10 January 2024Thursday, 11 January 2024Monday, 15 January 2024Tuesday, 16 January 2024Wednesday, 17 January 2024Thursday, 18 January 2024
CHILD INFORMATION
Full Name*

First Name Last Name
Gender*

MaleFemale
Primary Language
Date of Birth*

Day Month Year
School Attending*
School Year (2024)*
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
CCS (Child Care Subsidy) Details
This is required to receive government subsidies.
Full Legal Name of Child* Child 3 .

First Name Last Name
CRN Number* Child 3 .
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 [email protected] 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.
ADDITIONAL INFORMATION
Please provide any information you feel the service should know about the child e.g. language, religion, court orders, additional needs etc.
PARENT/GUARDIAN DETAILS
PRIMARY PARENT/GUARDIAN

This person's details are used to claim government subsidy.
Full Name*

First Name Last Name
Relation to child*

FatherMother
E-mail *
Phone (Mobile)*
Phone (Home)

Address*

Street Address
Street Address Line 2
City	State / Province
Post Code	Country

Authorisation*

CollectionExcursion AuthorisationEmergency CareMedical CareTransportationAllowed to sign child in/outAllowed to confirm sign in/out
CCS (Child Care Subsidy) Details

This is required to receive government subsidies.
Full Legal Name of Parent Registered for CCS*

First Name Last Name
Date of Birth*

Day Month Year
CRN Number*
SECONDARY PARENT/GUARDIAN
Full Name* Secondary Parent/Guardian .

First Name Last Name
Relation to child* Secondary Parent/Guardian .

FatherMother
E-mail*
Phone (Mobile)*
Phone (Home)

Address*

Street Address
Street Address Line 2
City	State / Province
Post Code	Country

Authorisation*

CollectionExcursion AuthorisationEmergency CareMedical CareTransportationAllowed to sign child in/outAllowed to confirm sign in/out
ADDITIONAL/EMERGENCY CONTACTS

Minimum 2 required. 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 your child or authorise excursions.
Additional/Emergency Contact 1
Full Name* Additional/Emergency Contact 1 .

First Name Last Name
Relation to child* Additional/Emergency Contact 1 .

GrandparentUncle/AuntFriend
E-mail*
Phone (Mobile)*
Phone (Home)

Address*

Street Address
Street Address Line 2
City	State / Province
Post Code	Country

Authorisation*

CollectionExcursionEmergencyMedicalTransportationAllow Sign In / OutAllow Confirm In / Out
Additional/Emergency Contact 2
Full Name* Additional/Emergency Contact 2 .

First Name Last Name
Relation to child* Additional/Emergency Contact 2 .

GrandparentUncle/AuntFriend
Relation to Child*
Phone (Mobile)*
Phone (Home)

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Authorisation*

CollectionExcursionEmergencyMedicalTransportationAllow Sign In / OutAllow Confirm In / Out
MEDICAL CONTACT INFORMATION
Doctor or Practice Name*

First Name Last Name or practice name
Relation to child*
E-mail
Phone (Work)*
Phone (Mobile)

Address*

Street Address
Street Address Line 2
City	State / Province
Post Code	Country

Authorisation*

EmergencyMedical
IMMUNISATIONS

The service needs to sight your child's Immunisation History Statement. Please email [email protected] with your child’s Medicare Immunisation form.
ENROLMENT AGREEMENTS

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 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 House of the North Shore Limited, 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 listed child/ren on the excursions for the days they are enroled (excursion list).
- I confirm I understand that the above listed child/ren will be photographed and videoed for the purposes of recording the wonderful services we offer, 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 - [email protected].
Sign by filling-in your full Legal Name*
PAYMENT INFORMATION

Please note: All bookings are final and there are no refunds or cancellations. For more information please see terms and conditions. Additionally, all bookings made within 2 business days of the requested day, will incur a late fee of $20 per child.

Payment is processed in full within 2 days of confirmation of this enrolment. You will be sent an email with a confirmed payment date.

If CCS has not been confirmed before than, you will be charged regular rates, and once CCS is confirmed, the balance will be credited to your account for future attendances.

Click here for rates.

Click here for more information about CCS.
Payment Method*

Direct DebitCredit Card (Surcharge of 1.1% Mastercard, 1.5% VIsa and 2% Amex)

Credit Card

We accept Visa, MasterCard, American Express
Credit Card Number
Expiration Month	Expiration Year

Bank:*
Account Name:*
BSB:*
Account Number:*
Please note: Your spot is only confirmed upon receipt of a full confirmation email. This can usually be expected within 3 business days of submitting the form.
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