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Enrolment Form

Please read our privacy disclaimer for the collection of information

Completing this form
- All sections of this form must be completed
- Fields marked with * are mandatory
- If you have difficulties or questioning about how to complete this form please speak to the centre director for assistance
A deposit of $300 is required to secure your place.
Deposit is non-refundable however it is credited to your account.
Account Name: Happy Toddlers Pty Ltd
BSB: 013304
Account Number: 197112785
This form must be completed by a parent or guardian who has lawful authority in relation to the child. A brief explanation of lawful authority is contained at the end of this form. The licensed children’s services must collect the child’s enrolment information in this form, as required by the Education and Care Services National Regulations 2011.
Attached documents*
Select those that apply
- Birth certificate
- Child health record
- Immunisation record
- Legal orders
- Health care card
Privacy
Leora Baby Centre acknowledges and respects the privacy of individuals. Personal information collected on the form and in processing your child’s enrolment application is collected and retained for the purposes of maintaining your child’s enrolment and financial institution payments if applicable. If you do not wish for your personal information to be used for these purposes Leora Baby Centre will not be able to process you child’s enrolment application. In addition to personal information collected to establish and maintain your child’s enrolment, in the course of your child’s enrolment Leora Baby Centre may also collect and retain personal information concerning your child’s health and physical condition. By entering into this agreement you agree that, to the extent reasonably necessary to enable provision of your child’s enrolment, Leora Baby Centre, its staff, agents, and their contracted services providers such as financial institutions and Government Agencies covered by law, may be recipients of such information. You have the right to access and alter personal information about your child retained by Leora Baby Centre in accordance with the Privacy Act 1988 (Cwth) and the full Privacy Policy of Leora Baby Centre, may be obtained at request at the Centre. You will receive communications from Leora Baby Centre from time to time to update you on matters relating to your child’s enrolment. Leora Baby Centre uses a variety of means of communication including mail, email, sms and telephone. By providing contact details relating to any of these forms of communication you consent to receiving communication and notice by those means.
About your child
CRN Child
Child Name*
First Last
Preferred name*
What would you like to call your child?
Child DOB*
Date Format: DD slash MM slash YYYY
Child Residential Address*
Street Address Address Line 2 City State Post Code
Telephone (H)*
Child Gender*
- Female
- Male
Is your child of Aboriginal, Torres Strait Island or Australian South Sea Island Origin?*
- Yes
- No
Original birth certificate sighted by
To be filled by the centre
Birth certificate attached?*
- Yes
- No
Municipality*
In which local government area does your child live?
Parent/Guardian 1
(Parent/Guardian 1 must be main contact with Centrelink for CCB/CCR purposes)
CRN Parent/Guardian 1
Name*
First Last
DOB*
Date Format: DD slash MM slash YYYY
Gender*
- Female
- Male
Residential Address*
Street Address Address Line 2 City State Post Code
Postal address different from residential address?*
- Yes
- No
Postal Address*
Street Address Address Line 2 City State ZIP / Postal Code
Phone (W)
Phone(H)
Mobile*
Email*
Enter Email Confirm Email
Country of birth*
Occupation*
Languages spoken at home*
English
Does the child live with this person?*
- Yes
- No
Relationship to child*
Parent/Guardian 2
CRN Parent/Guardian 2
Name*
First Last
DOB*
Date Format: DD slash MM slash YYYY
Gender*
- Female
- Male
- Copy Residential Address Of Parent/Guardian 1?
Residential Address*
Street Address Address Line 2 City State Post Code
Postal address different from residential address?*
- Yes
- No
- Copy Postal Address Of Parent/Guardian 1?
Postal Address*
Street Address Address Line 2 City State Post Code
Phone (W)
Phone(H)
Mobile*
Email*
Enter Email Confirm Email
Country of birth*
Occupation*
Languages spoken at home*
English
Does the child live with this person?*
- Yes
- No
Relationship to child*
Attendance days required*
Monday Tuesday Wednesday Thursday Friday
Commencement date*
Date Format: DD slash MM slash YYYY
Does the child has siblings?*
- Yes
- No
Name
Full Name
DOB
Date Format: DD slash MM slash YYYY
Gender
- Female
- Male
Custody of child
Have any orders been made by any court regarding your child?*
- Yes
- No
Please attach a copy of the order and provide any details of guardianship, custody and terms of any specific custody or access provision.
Which days does the child live with the mother?
From day & time...To day & time
Which days does the child live with the father?
From day & time...To day & time
Please discuss your family situation with the Centre Director.
Parent/Guardian signature
(Use your mouse to sign your name. On touch screen use your finger)
Medical Information
Maternal and Child Health (MCH) Centre*
Doctor’s Name*
Doctor's Address*
Doctor's Telephone*
Medicare Number*
Child Ref*
Please enter a number from 1 to 9.
Contacts/Authorisations
Emergency Contacts
Please provide the name, address and contact details of any person who is to be notified of an emergency involving the child if any parent of the child cannot be immediately contacted
Name
First Last
Relationship to child
Address
Street Address Address Line 2 City State Post Code Country
Phone(W)
Phone(H)
Mobile
Authorised Nominee
Please provide the name, address and contact details of any person who has been given permission by a parent or family member to collect the child from the childcare centre.
- Copy emergency contact(s) to authorised nominee?
Name
First Last
Relationship to child
Address
Street Address Address Line 2 City State Post Code Country
Phone(W)
Phone(H)
Mobile
Medical Administration Contacts
Please provide the name, address and contact details of any person who is authorised to consent (authorised person) to medical treatment of the child or to authorise the administration of medication to the child.
- Copy emergency contact(s) to medical administration?
Name
First Last
Relationship to child
Address
Street Address Address Line 2 City State Post Code Country
Phone(W)
Phone(H)
Mobile
Medical Transport and/or advice from a medical practitioner
Please provide the name, address and contact details of a parent or a person who is authorised for the childcare centre, nominated supervisor or 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
- Copy emergency contact(s) to medical transport?
Name
First Last
Relationship to child
Address
Street Address Address Line 2 City State Post Code Country
Phone(W)
Phone(H)
Mobile
Contact for taking a child outside of the childcare service
Please provide the name, address and contact details of any person who is authorised to authorise an educator to take the child outside the education and care service premises
- Copy emergency contact(s) to outside contact(s)?
Name
First Last
Relationship to child
Address
Street Address Address Line 2 City State Post Code Country
Phone(W)
Phone(H)
Mobile
Getting to know your child

Special Considerations
Are there any special considerations for the child, for example any cultural, religious or dietary requirements or additional needs?*
- Yes
- No
Please specify*
Select one of the following*
- I know of no medical or other condition, circumstance or risk which my child has that may impact on or adversely affect my child’s involvement in any activity, program or service in which my child may participate.
- My child has the following condition/additional needs/disability which may impact on their participation in any activity program or service
Please specify*
Has your child received all the recommended immunisations according to the NHMR (National Health & Medical Record Council)?*
- Yes
- No
Please provide a copy to the Early Learning Director and show the original
Original sighted by
To be filled by the centre
Date
To be filled by the centre
If No or Exempt, please provide details*
Medical Exemption Certificate as provided by your Doctor*
- Yes
- No
Has your Child’s Health Record/Immunisation been provided for staff to sight?*
(Please provide copies of immunisation)
- Yes
- No
Original sighted by
To be filled by the centre
Date
To be filled by the centre
Does your child require regular medication?*
- Yes
- No
If Yes, you will be required to complete an approval for ongoing medication form.
Does your child have known allergies or sensitivity?*
- Yes
- No
If Yes, please provide a current Allergy Action Plan signed by their Doctor
Has your child been diagnosed as at risk of Anaphylaxis?*
- Yes
- No
If ‘Yes’ please provide a copy of their Anaphylaxis Management Plan signed by their Medical Practitioner.
Does your child have an auto injection device (e.g. an Epipen or Anapen)? (Please note: An Epipen must be handed to staff on sign in)*
- Yes
- No
Has a risk minimisation plan been completed by the service in consultation with you? Please refer to the Parents Handbook for details on Anaphylaxis Management.*
- Yes
- No
Has your child been diagnosed with Asthma?*
- Yes
- No
If Yes, please provide a copy of their Asthma Management Plan signed by their Doctor.
Does your child have specific dietary requirements?*
- Yes
- No
Please specify*
Does your child have any additional needs?*
- Yes
- No
Please specify*
Babies
Is your child breast fed?
- Yes
- No
Details
All other bottle feeding requirements.
- Formula
- Cow's milk
- Soy milk
Does your child eat solid foods?
- Yes
- No
Details
Can your child sit alone?
- Yes
- No
Can your child crawl?
- Yes
- No
Can your child walk?
- Yes
- No
General
Food and drink
My child enjoys eating
My child does not eat
Play Preferences
Please list your child’s favourite song’s stories toys or activities:
Toileting
Is your child in nappies?
- Yes
- No
Is your child currently toileting?
- Yes
- No
Are there any special words that you use with your child for toileting?
More getting to know your child

Sleep Routine
Any special bedtime/day sleep routines (including approximate time and details on how your child is assisted to sleep)?
Does your child have any comfort items at sleep time?
Festivals and celebrations
Please provide details of the festivals/celebrations your family recognises.
Additional Information
Declarations
I*
(print Parent/Guardian name)
A person with lawful authority of the child referred to in this enrolment form,
I authorise staff to re-apply sunscreen to my child while attending Leora Baby Centre*
- Yes
- No
Do you give permission for your child to be photographed of filmed for the purpose of publicity and/or promotions for Leora Baby Centre?*
- Yes
- No
Do you give permission for your child to be photographed for the purpose of curriculum planning – observations and portfolios and for display purposes within the Centre.*
- Yes
- No
- I agree to immediately collect or make arrangements for the collection of the child referred to in this enrolmentform if she/he becomes unwell at the service
- I agree to inform and update the Early Learning Centre staff of all medical care requirements of my child whilst in their care. This includes information of the management of any medical condition, any medication required to be administered and any medication or other substances that should not be provided or administered to a child
- I agree that the ongoing management of the child/Children’s’ medical condition, if any, remains my sole responsibility and is not and does not under any circumstances become the responsibility of Leora Baby Centre Staff
- I accept full responsibility for my children’s belongings whilst taking part in the program
- I agree to inform the program if my child contracts any illness which could be detrimental to health of others at the program
- I agree and fully understand the guidelines and policies of the Service as outlined in the Procedure Manual,including all aspects of the fee policy and agree to adhere to these
- I acknowledge that due to Children’s Services Regulations and Childcare Benefit requirements there may be times when my child’s full name will be displayed at the service, in records which include but is not limited to: the Sign In and out book, incident report book and action plans. If I have concerns about this issue I will advise the service in writing
- I am aware that it is my responsibility to maintain a current Family Assistance Office income Assessment notice for Childcare Benefit (CCB). Upon enrolment fees are to be paid two weeks in advance to ensure an ongoing place at the Early Learning Service
- I understand to withdraw from Leora Baby Centre I must provide one month written notice to the Early Learning Director
- I understand that it is my responsibility to promptly advise Leora Baby Centre of any changes to the medical issues or change to the legal authority with respect the child outlined on the enrolment form
- I understand that Leora Baby Centre may telephone me and ask me to pick up my child earlier than the designated time due to illness or as the result of an accident at the Early Learning Service that may require further medical attention by the child’s doctor
- I understand that doctor’s certificate may be required to allow my child to return to child care
- I understand that in the case of a medical emergency an ambulance will be called in the first instance and the child may be transported by ambulance if required
- I understand that all medical and transport costs are payable by me and are my responsibility. The parent or guardian will be contacted by the Early Learning Director as soon as possible to inform them of their child’s status. In the event the parents or guardian cannot be contacted a voice message will be left and the emergency contacts as detailed on the enrolment form will be contacted. The Early Learning Director will oversee all aspects of the emergency and continue to attempt to contact the parents or guardian by telephone
I declare that the information I have provided in this enrolment form is true and correct and understand that it is my responsibility to immediately inform the Early Learning Director of any changes or updates to this information. I have read and understood the Parents’ Handbook and understand all policies and procedures and that I can contact the Early Learning Director if I have any questions relating to any aspect of the Early Learning operations.
Name*
Parent/Guardian full name
Date*
Date Format: DD slash MM slash YYYY
Parent/Guardian signature*
(Use your mouse to sign your name. On touch screen use your finger)
File Uploads
If you have files to attach with this application such as immunisation record, birth certicate, etc., please upload them here
Drop files here or

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