Palmwoods Kids Club Enrolment Form
  1. Child's Full Name
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  2. Gender
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  3. Date Of Birth
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    Please provide a birth certificate to Palmwoods Kids Club
  4. Class Year
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    Childs year level
  5. Does this child identify as an Aboriginal
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  6. Does this child Identify as a South Sea Islander
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  7. Does this child identify as a Torres Strait Islander
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  8. School Child Attends
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  9. Childs Ethnicity
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  10. Childs Religion
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  11. Childs Cultural Background
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  12. Childs Country of Birth
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  13. Language Spoken at Home
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  14. Interests









    (Please select ONE of the following which best applies to your child's current interests)
  15. What goals would you like to see your child achieve while at Kids Club
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  16. Child's address
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  17. Childs Immunisation Statues
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    If immunised please provide a copy of the immunisation certificate
  18. Childs CRN
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  19. Name of Childs Doctor
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  20. Telephone of Doctor
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  21. Doctors Address
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  22. Medicare Number
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  23. Private Health Insurance Fund
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  24. Does Your Child Require Regular Medication
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  25. Does Your Child Have Any Known Allergies or Sensitivities
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    If so, please specify below and provide a current Allergy Plan, signed by a Medical Practitioner and include a colour photo of your child
  26. Allergy or Sensitivity
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  27. Has this child been diagonosed as At risk of Anaphylaxis
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    If so, please provide a copy of this child's Anaphylaxis Management Plan, signed by a Medical Practitioner
  28. Has your Child been diagnosed with Asthma
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  29. Does your child have additional needs
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    If so, please specify
  30. Does your child have any dietary requirements or restrictions
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    If so, please specify
  31. Are there any Court Orders, Parenting Orders or Parenting Plans
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  32. Are there any Court Orders regarding the power and responsibilities of the parents in relation to the child or access to the child
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    If so, please bring the original court orders for the staff to sight and to copy
  33. Type of booking
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  34. (Only tick days which will be required every week)
  35. Before school care booking
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  36. (Only tick days which will be required every week)
  37. After school care booking
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  38. Start Date
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    Please indicate the date of your child's first attendance at Kids Club
  39.  
  1. Enrolling Parent or Guardians details
  2. Enrolling parents or guardians name
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  3. Sibling Details
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    Sibling name, Sibling Date of Birth, Name of child care services sibling is attending
  4. Relationship to Child
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  5. Cultural Background
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  6. Enrolling Parent or guardians CRN
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  7. Will CCR be paid directly to Palmwoods Kids Club
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  8. How much CCR has this child received during this financial year
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  9. Email
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  10. Date Of Birth
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  11. Address
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  12. Postal Address
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    Only required if different from address
  13. Home Phone
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  14. Mobile Phone
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  15. Work Phone
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  16. Employer
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  17. Occupation
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  18. Work Address
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  19. Do you as the enrolling parent or Guardian have any skills or interests that can be utilised as part of our program throughout the year for example woodworking cooking dance please state them below
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  20. Other Contacts
  21. Other legal parents or guardians name
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  22. Relationship to Child
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  23. Cultural Background
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  24. Address
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  25. Home Phone
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  26. Mobile Phone
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  27. Work Phone
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  28. Additional Authorised Nominees
  29. Name
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  30. Relationship to Child
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  31. Address
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  32. Home Phone
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  33. Mobile Phone
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  34. Work Phone
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  35. May we contact this person in an emergency
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  36. Do you give this person permission to collect this child
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  37. Do you give permission for this person to make and cancel booking on your behalf
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  38. Do you authorise this person to consent to Medical Treatment and administration of medication
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  39. Contact 1
  40. Name
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  41. Relationship to Child
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  42. Address
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  43. Home Phone
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  44. Mobile Phone
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  45. Work Phone
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  46. May we contact this person in an emergency
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  47. Do you give this person permission to collect this child
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  48. Do you authorise this person to consent to Medical Treatment and administration of medication
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  49. Do you give permission for this person to make and cancel booking on your behalf
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  50. Contact 2
  51. Name
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  52. Relationship to Child
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  53. Address
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  54. Home Phone
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  55. Work Phone
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  56. Mobile Phone
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  57. May we contact this person in an emergency
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  58. Do you authorise this person to consent to Medical Treatment and administration of medication
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  59. Do you give this person permission to collect this child
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  60. Do you give permission for this person to make and cancel booking on your behalf
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  61. Palmwoods Kids Club Terms and Conditions: Please sign below to indicate your desire to have your child enrolled, agreeing to adhere to terms and condition of enrolment as outlined in the Family Handbook 2016. I undertake the following—to inform the centre of any absence of my child; to keep my child from attending should they be suffering any infectious or contagious disease and headlice and to ensure that my child is collected by an authorised person or according to arrangements made in writing. I am also willing for my child to participate in all activities offered in the programs, including incursions. I agree it is my responsibility to familiarise myself with the programs and to advise the service in writing if I do not wish my child to participate in a particular activity. I also authorise Kids Club staff to discuss relevant information regarding my child with Palmwoods State School Staff and Support Workers, when necessary, in order to better care for my child. I also give permission for photos/videos of my child to be displayed for promotional purposes and also in various publications including an annual DVD which is distributed to all families. Please put a cross in the relevant box if you do not want your child to appear in a particular type of publication. Displayed in Service PKC Website Newspaper articles PKC DVD I agree to treat all staff with respect. I agree to allow staff to deal with my child and other children’s behaviour at Kids Club, and not to seek contact with other children over their behaviour. I agree to keep the payment of my account up to date (no more then 7 days), or I will arrange with Kids Club for a payment plan to be put in place. Otherwise, I understand that if my account is 7 days in arrears, that my child may not be able to attend Kids Club until the amount owing is paid and that moving forward, I may be required to pay in advance. In the event of the Customer being in default of their obligation to pay and the overdue account is then referred to a debt collection agency, and/or law firm for collection the Customer shall be liable for the recovery costs incurred and if the agency charges commission on a contingency basis the Customer shall be liable to pay as a liquidated debt, the commission payable by the Supplier to the agency, fixed at the rate charged by the agency from time to time as if the agency has achieved one hundred per cent recovery and in the event where the Supplier or the Supplier's agency refers the overdue account to a lawyer the Customer shall also pay as a liquidated debt the charges reasonably made or claimed by the lawyer on an indemnity basis. I also understand and agree that if my child is picked up after 6.00pm, that a fee of $15.00 per quarter hour per family will be charged to my account. I understand that significantly overdue accounts will be referred to a collection agency where all fees incurred will be at my expense and that I may be permanently excluded from using the service. I understand that my account and receipts will be e-mailed to me, unless otherwise arranged with the Coordinators or Operations Manager. In case of an emergency every effort will be made to contact the parents prior to taking action or seeking treatment. In the event of my child receiving injuries requiring urgent medical treatment, I authorise the Palmwoods Kids Club Educators to obtain the medical assistance which she or he deems necessary and consent to my child going in an ambulance if the need arises. I agree to pay all medical and transport costs incurred on behalf of my child. I further authorise qualified and medical authority to administer anaesthetic and necessary pain relief if the need arises. I consent to the administration of life saving medication (e.g Epipen or Ventolin) in emergency situations. I understand that the service is unable to care for sick children or children with contagious illnesses. Medicine will be administered to children, only by the receipt of and under written authorisation from parents and medical authority. The medication must have a pharmacy label on it with the child’s name, dosage and expiry date. I understand it is my responsibility as parent/guardian to supply the service with the correct information that is required to be eligible for CCB and CCR. I agree to notify the service in writing of any changes to the information stated on the enrolment, within 2 weeks. I give permission for my child to wear sunscreen supplied by the service.
  62. Name signature(*)
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    Please enter your full name to serve as and electronic signature which accepts the above terms and conditions
  63. Submit