CASEY.VIC.GOV.AU

This form must be completed by a parent for each child enrolled in the Education and Care Service (the Service). If you require assistance completing this form, please contact City of Casey Family Day Care on 9705 5200.

1. Information about the child - please print clearlyGiven name/s: ________________________________________________________________________

Family name: _________________________________________________________________________

Date of birth: ________________________________ Gender: Male Female

Child’s home address __________________________________________________________________

____________________________________________________________________________________

Language(s) spoken in the child’s home: ___________________________________________________

Cultural background (if applicable): ________________________________________________________

Is the child of Aboriginal and/or Torres Strait Islander origin? Yes No

2. Information about the child’s parents - Persons with Authority

Parents The definition of the ‘parent’ according to National Law is:» (a) a guardian of the child; and» (b) a person who has parental responsibility for the child under a decision or order of the court.

Parent’s partners:A relationship that arises by marriage (including a de facto relationship) cannot be included as a ‘parent’ unless the person has obtained parental responsibility for the child under a decision or order of a court.

Family members:Other persons such as family members other than parents, with whom the child permanently resides, also fall within the definition of a ‘family member.’ Unless they have sought legal guardianship or have obtained parental responsibility for the child under an order or decision of the court, they cannot be listed as a parent.

Educator/Staff Use only: additional information enclosed in this record:

Dietary Restrictions Photo Consent Restrictions Court Orders/Parenting Plans

Medical Conditions Non-immunised/catch up program Other:

City of Casey Family Day Care Printable version 1

Child’s Confidential Record

Parent 1Given name: _________________________________________________________________________

Family name: _________________________________________________________________________

Relationship to child: Mother Father other: _____________________________________

Does the child live with this parent? Yes No

Address same as child: Yes or: ________________________________________________________

Home phone: _________________________ Mobile phone: ___________________________________

Work phone: __________________________Email address: ___________________________________

Hours of work/study: Full time Part Time Casual

Name and location of work/study place: ____________________________________________________

____________________________________________________________________________________

Language(s) spoken by the parent: _________________________Interpreter required Yes No

Parent 2 Given name: _________________________________________________________________________

Family name: _________________________________________________________________________

Relationship to child: Mother Father other: _____________________________________

Does the child live with this parent? Yes No

Address same as child: Yes or: ________________________________________________________

Home phone: _________________________ Mobile phone: ___________________________________

Work phone: __________________________Email address: ___________________________________

Hours of work/study: Full time Part Time Casual

Name and location of work/study place: ____________________________________________________

____________________________________________________________________________________

Language(s) spoken by the parent: _________________________Interpreter required Yes No

3. Court orders, parenting orders or parenting plans relating to the child (a) Are there any court orders, parenting orders or parenting plans relating to the powers, duties and

responsibilities or authorities of any person in relation to the child or access to the child?

No Yes, please attach

(b) Are there any other details of court orders relating to the child’s residence or the child’s contact with a parent or other person?

No Yes, please attach

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4. Authorisations: details of people the parent authorises as contacts for the child other than those listed as parents in section two

Definitions» Authorised to collect (Authorised Nominee) the child from the education and care service

» Authorised to be notified of an emergency involving the child if any parent cannot be contacted

» Authorised to consent to medical treatment

» Authorised to consent to administration of medication

» May authorise an educator to take the child outside of the service on excursions/regular outings

» May authorise an educator to take the child outside of the service premises

List the details of those persons who you authorise as contacts for the child. Please complete all fields. The list may be amended at any time. An additional copy of this page can be obtained from the educator.  I ___________________________________________ (Print full name) nominate the person/s listed below as authorised contacts for the child.

Parent signature: _____________________________________________________ Date ___ /___ /___

Contact 1: (not including those listed as parents in section two)Full name: ___________________________________________________________________________

Address: _____________________________________________________________________________

Home phone: ______________________________ Work phone: ________________________________

Mobile phone: ______________________________ Relationship to child: _________________________

Please tick the box/es below to confirm the level of authorisation you give to this person Authorised to collect (Authorised Nominee) Authorise to be notified of an emergency involving the child if any parent cannot be contacted Authorised to consent to medical treatment Authorised to consent to administration of medication May authorise an educator to take the child outside the service on excursions/regular outings May authorise an educator to take the child outside the service premises

Contact 2 (not including those listed as parents in section two)Full name: ___________________________________________________________________________

Address: _____________________________________________________________________________

Home phone: ______________________________ Work phone: ________________________________

Mobile phone: _____________________________ Relationship to child: __________________________

Please tick the box/es below to confirm the level of authorisation you give to this person Authorised to collect (Authorised Nominee) Authorise to be notified of an emergency involving the child if any parent cannot be contacted Authorised to consent to medical treatment Authorised to consent to administration of medication May authorise an educator to take the child outside the service on excursions/regular outings May authorise an educator to take the child outside the service premises

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5. Attendance at another children’s serviceDoes the child attend another child care, outside school hours, family day care or kindergarten service? No Yes If yes, provide details:

Service name: ________________________________________________________________________

Days/times of attendance: ______________________________________________________________

6. Child’s immunisation and health informationImmunisationBy law, the service is required to obtain evidence of immunisation. Acceptable documentation includes one of the following.

» Immunisation History Statement – issued by the Australian Childhood Immunisation Register

» Immunisation Status Certificate – Issued by the child’s Immunisation Provider

Immunisation records that are not acceptable as evidence of the child’s immunisation status include:

» the child’s Health Record (blue book) Health & Development Record (green book)

» overseas immunisation records

» ‘homeopathic immunisation’

» statutory declarations

» DHS Medicare repository Services immunisation encounters

Conscientious objection and vaccination objection on non-medical grounds are not valid exemptions from immunisation requirements.

Immunisation History Statements can be requested at any time by contacting Medicare: » Phone 1800 653

809 » Email acir@medicareaustralia.gov.au

» Visit the Medicare website

» Visit your local Medicare office.

A copy of the child’s immunisation status is attached Yes No

MedicalName of doctor:_______________________________________________________________________

Name of medical service: _______________________________________________________________

Address: _____________________________________________________________________________

Telephone: ___________________________________________________________________________

Child’s Medicare No. (If available): __________________________________________Not available

Maternal & Child Health Centre: __________________________________________________________

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Child’s specific medical conditions

Medical ConditionsHas the child been diagnosed as being at risk of anaphylaxis? Yes No

Has the child been prescribed an adrenaline auto-injector device? (AAID) Yes No

Has the child been diagnosed with asthma? Yes No

Has the child been diagnosed with epilepsy? Yes No

Has the child been diagnosed with diabetes? Yes No

If yes to any of the above, the parent is required to provide an Action Plan (available from a medical practitioner) specific to the child’s diagnosed condition that has been completed by the medical practitioner

You will be provided with a copy of the City of Casey Child Youth & Family Guideline relevant to the medical condition and a Risk Minimisation & Communication Plan to be completed with the educator before the child commences care.

AllergiesDoes the child have any diagnosed allergies? Yes No

If yes, please request a City of Casey Allergy Management Plan from the City of Casey to be completed by a medical practitioner.

The City of Casey will also provide a copy of the City of Casey Allergy Management Guidelines and an Allergy Risk Minimisation & Communication Plan to be completed with the educator before the child commences care.

Dietary Restrictions

Does the child have any dietary restrictions? (including cultural or religious considerations) Yes NoIf yes, please request a Dietary Restrictions form from the City of Casey to complete.

7. Child’s Cultural/Religious/Specific Health Care/Developmental NeedsThe City of Casey is committed to providing an environment that values and respects the needs of all children to fully participate. The programs are planned to accommodate the individual needs of all children

» Does the child have any additional health care needs, medical conditions or diagnosis that are relevant to the education and care of the child?..................................... Yes No

» Do you have any concerns regarding the child’s development............................................ Yes No

» Do you believe the child may need any other additional support or guidanceto participate fully in the program?....................................................................................... Yes No

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» Are special cultural or religious considerations required for the child/family?...................... Yes

No

If you have answered yes to any of the questions above please provide details below, to assist educators to maximise the child’s participation and ensure full inclusion. If required attach a separate page.

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

Is the child linked to other professional services e.g. paediatrician, early intervention service, therapists, Preschool Field Officers, Inclusion Support Facilitator:

Professional service name: _____________________________________________________________

Contact name and details: ______________________________________________________________

Do you authorise the educator to communicate with this service to support the child’s health and wellbeing? Yes No

Professional service name: _____________________________________________________________

Contact name and details: _______________________________________________________________

Do you authorise the educator to communicate with this service to support the child’s health and

wellbeing? Yes No

8. Request for educators to apply sunscreen

A parent’s consent is required before sunscreen can be applied to the child.

» This authorisation remains valid until such time that the parent notifies the educator in writing of change.

» It is the responsibility of the parent to ensure that the sunscreen is provided daily between September and April and at other times as required.

» Parents are to ensure that the sunscreen is applied to their child at least 20 minutes before arrival at the service and the educator will supervise further applications as required throughout the day in accordance with the Weather Protection Guidelines

» The sunscreen provided should be clearly labelled with the child’s name, be a minimum of 30+ and within expiry or use by date.

» Parents are responsible for the replacement of any used or out of date sunscreen.

» The educator will advise the parent if the sunscreen needs replacing.

» Parents and educators must notify each other immediately if there is any evidence of an allergic reaction following the application of sunscreen.

» Children over four years will be encouraged to apply their own sunscreen under supervision. I authorise the educator/s at my child’s service to apply the sunscreen I have provided for my child as required and in accordance with the instructions contained in the Weather Protection Guidelines

I authorise the educator/s at my child’s service to apply sunscreen provided by the service in the event that I have not provided my child’s own, in accordance with the instructions within the Weather Protection Guidelines. I understand that the brands used may vary according to availability.

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9. Filming/Photography ConsentA parent’s consent is required before taking images or recordings of their child.

In line with the City of Casey Children’s Plan, Children’s Services advocate for the rights of each child as a valued member of the community. Staff and educators of the City of Casey will engage in verbal consultation with children that is respectful, ethical and genuine prior to any filming or recording of them.

Specific agreementBy signing this form, I understand and give permission for myself and/or the child to be filmed and/or photographed and the images obtained, used in accordance with my selection below.

Within the children’s service (FDC educator residence):» program documents, newsletters, child’s portfolio, wall displays............................... Yes No

» electronically provided to me (the parent) containing images of the child.................. Yes No

» electronically provided to other parents that may contain images of the child........... Yes No

City of Casey use outside of the children’s service:» power point presentations at meetings and training................................................... Yes No

» playgroups, family events and celebrations............................................................... Yes No

» newsletters, brochures, journals................................................................................. Yes No

» educator/ staff emails................................................................................................. Yes No

» advertising in newspapers, websites and other media outlets................................... Yes No

» media and publications (e.g.; the City of Casey website, annual report, Children’s Plan, brochures and banners)................................................................... Yes No

Please indicate for whom your permission applies:» Myself......................................................................................................................... Yes No

» The child as listed on this Child’s Confidential Record............................................... Yes No

I _______________________________________________________ (insert full name) understand that:

» when I receive images electronically and there are other children in the image I cannot forward these images or use them without the permission of the families in the image

» the child’s first name and age may be used to acknowledge any of the child’s images if they are published

» the images may be used in new publications by the City of Casey for the duration of two years

» the child and I are able to withdraw our consent at any time

» the City of Casey will maintain confidentiality of both my and the child’s information along with any of our images

» if photo consent is required that does not fall within the above parameters, the educator will obtain specific consent to suit the individual circumstances

» the City of Casey will respect my right to not provide consent but cannot always prevent members of the public or other families from taking images of myself or the child at kindergarten events such as end of year celebrations

Parent full name: _____________________________________________________________________

Parent signature: ____________________________________________________Date ___ /___ /___

10. Scheduled care required – parent to completeHave you previously registered with the City of Casey Family Day Care Scheme? Yes No

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Commencement date requested: ___ /___ /___

Type of care required (please tick options below)

Booked Care Before and After School Care Casual Care School Holiday Care

Actual hours of care required for the non-school child: (minimum of 5 hours)

Mon Tues Wed Thurs Fri Sat Sun

Care start time

Care finish time

Do you require the educator to drop off or collect the child from kindergarten? Yes No

If yes, name and suburb of the kindergarten: _______________________________________________

Mon Tues Wed Thurs Fri Sat Sun

Drop of time

Collection time

Actual hours of care required for the school child: (minimum of 2 hours)

Do you require your child to be dropped off or collected from school? Yes No

If yes, name and suburb of the school: _____________________________________________________

Mon Tues Wed Thurs Fri Sat Sun

Before school care start time

School drop off time

After school collection time

After school care finish time

Do you require care during school holidays? Yes No

Mon Tues Wed Thurs Fri Sat Sun

Drop off time

Collection time

11. Child Care Benefit and Child Care Rebate

In order for the service to provide Child Care Benefit (CCB), the person applying for CCB must provide their Customer Reference Number (CRN) and the CRN of the child.

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Name of the person who is registered/applying for CCB:

Parent full name: ____________________________________ Relationship to child: _____________

Parent date of birth: _________________________________ CRN: __ __ __ __ __ __ __ __ __ __

Child’s full name: ____________________________________ CRN: __ __ __ __ __ __ __ __ __ __

12. Declaration and Consent

I _____________________________________________________________ (print full name) the

person having authority for the child referred to in this Child’s Confidential Record:

» declare that the information in this Child’s Confidential Record is true and correct and undertake to immediately inform the educators at the service in the event of any change to this information

» understand that in an emergency situation or drill where evacuation is necessary that the child may need to leave the service under the direction and supervision of the educators

» authorise the approved provider, nominated supervisor or educators at the service to seek necessary medical treatment for the child from a registered medical practitioner, hospital, dental or ambulance that includes the transportation of the child by an ambulance from the service in the event of an emergency. I agree that all associated medical expenses will be my responsibility.

» understand that the City of Casey complies with the Information Privacy Act 2000 in relation to the collection of information contained within this Child’s Confidential Record

» have read the service information on the City of Casey website and understand the conditions under which I am enrolling the child and will abide by the fee payment terms

Parent full name: ______________________________________________________________________

Signature: ____________________________________Date: ___________________________________

Parent 2 (optional) full name: _____________________________________________________________

Signature: ____________________________________Date: ___________________________________

Privacy Statement Your personal information will be handled in accordance with the Privacy and Data Protection Act 2014 and used for the specified purpose. You can access your personal information by contacting Council’s Privacy Officer on 9705 5200

13. Office/educator use

Family ID: __________________________________ Child Number: _____________________________

ECM ID: ___________________________________ Date of Application: _________________________

Immunisation assessment

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Acceptable evidence of the child’s immunisation status is attached to this record Yes

The child is eligible for the 16 week Grace Period. Yes

The Immunisation grace period eligibility assessment form is attached Yes

First Review of immunisation status:

Has the child received further immunisation since enrolment? Yes No

If yes, attach a copy of the child’s immunisation status copy attached

Second Review of immunisation status:

Has the child received further immunisation Yes No

If yes, attach a copy of the child’s immunisation status copy attached

Review Date: ___ /___ /___ Review Date: ___ /___ /___ Review Date: ___ /___

/___ Child’s Confidential Record checked/updated by the educator/staff:

Anaphylaxis:Parent provided with a copy of the Anaphylaxis Management Guidelines Date ___ /___/ ___Anaphylaxis Management Plan and RMCP attached Date ___ /___/ ___Asthma:Parent provided with a copy of the Asthma Management Guidelines Date ___ /___/ ___Completed Asthma Action Plan and RMCP attached Date ___ /___/ ___Epilepsy:Parent provided with a copy of the Epilepsy Management Guidelines Date ___ /___/ ___Completed Epilepsy Action Plan and RMCP attached Date ___ /___ /___Diabetes:Parent provided with a copy of the Diabetes Management Guidelines Date ___ /___/ ___Completed Diabetes Action Plan and RMCP attached Date ___ /___/ ___Allergies:Parent provided with a copy of the Allergy Management Guidelines Date ___ /___/ ___Parent provided with a City of Casey Allergy Management Plan Date ___ /___/ ___Completed City of Casey Allergy Management Plan and RMCP attached: Date ___ /___/ ___Dietary Restrictions:Completed Dietary Restrictions form attached: Date ___ /___ /___

Educator/staff full name: ________________________________________________________________

Educator/staff signature: _________________________________________________Date: ___/___/___

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