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School Holiday Program - Summer 2011

Parent/Guardian must complete this form.

Please complete fields marked with

Important! Please Read Dear Parent The City of Greater Geelong School Holiday Program is now regulated under the Children's Services Regulations 2009 and the Children's Services Act 1996 (Amended May 2009).
Centrelink Reference Number for this family:	When enroling online you are required to complete a consent authorisation form, which will be sent to you upon receipt of your enrolment. This form must be signed and returned to us prior 20th December 2010.

Parent/Guardian Details
First Name:
Surname:
Relationship to Child:	Please select Aunt Father Friend Grandparent Guardian Mother Other Please Select Sibling Step Parent Uncle
Date of Birth:	Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900
Home Phone:
Work Phone:
Mobile:
Email:
Street Address:
Suburb:
Postcode:
Does the child live with this parent/legal guardian?	YesNo
Is this person authorised to collect your children?	YesNo
Do you give permission for School Holiday Program to contact you by SMS message on your mobile phone?	YesNo
Are you responsible for payment?	YesNo If no, please provide details of responsible person

Add Other Parent/Guardian?	YesNo

Background Information
Has your child/ren attended the CoGG School Holiday Program before?	YesNo
Are you an Aboriginal or Torres Strait Islander family?	YesNo
Are there any Court Orders that effect any of the children listed on this enrolment application? If yes, a copy of the Order is required by the School Holiday Program.	YesNo
Do you give your permission for your child/ren to watch PG rated movies under the supervision of SHP Staff during the program?	YesNo
Do you give permission for the School Holiday Program staff to supply your child with sunscreen and insect repellant and if needed help your child apply it (using gloves)?	YesNo
What is the primary language spoken at home?
The Family ethnic origin:
The Country of birth:
How many of your children will be attending OTHER approved childcare services during the school holidays?(Eg. Long Day Care, Family Day Care.)	Please select 0 1 2 3 4 5
Please indicate the reason for requiring care at the School Holiday Program?
Working/Seeking Work	YesNo
Studying	YesNo
Social Care	YesNo
Respite	YesNo

Child Care Benefit (CCB)
Please select:	I would like to claim Child Care Benefit (CCB) as reduced fees I would like to claim CCB as a lump sum I do not want to claim Child Care Benefit NOTE - ALL of your children MUST be linked to the service they will be attending to claim reduced fees. Contact the Family Assistance Office on 13 61 50 to link ALL your children. Further information can be found on their website www.familyassist.gov.au
Family Assistance Office	Have you registered with the Family Assistance Office to claim Child Care Benefit? YesNo

Child's Details
Child's Name:
Address of child:
Child's CentreLink Ref Number:
Date of Birth:	Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900
Gender:	MaleFemale
Year level in 2011:
School Attended:
Does this child have any additional needs? YesNo If yes, please provide details
Does this child have any allergies or sensitivities? YesNo If yes, please provide details
Anaphylaxis
Has this child been diagnosed at risk of anaphylaxis? YesNo If yes, Please answer the following:
Does your child have an auto injector device (eg Epipen)? YesNo
Have you provided our service with an Anaphylaxis medical management plan? YesNo
Asthma
Has this child been diagnosed with Asthma? YesNo
If Yes, have you provided an Asthma Management Plan? YesNo
Medical Conditions
Does this child have any other medical conditions? (eg epilepsy, Diabetes etc) YesNo If yes, please provide details of any medical condition and any management procedure to be followed in respect to this condition.
Does this child have any dietary restrictions? YesNo If yes, the following restrictions apply
Is this child fully immunised? YesNo
Provided Medical Management Plan YesNo

Add Additional Child?	YesNo

Booking Information
Please select:	1st preference venue Belmont Leopold Newtown North Shore Ocean Grove
Another Centre?	If there are not sufficient places at this centre, would you like to be placed at another centre? YesNo
Please select:	2nd preference venue Belmont Leopold Newtown North Shore Ocean Grove
Select days:
Please note: Please note Newtown, Ocean Grove & Leopold programs conclude on the 21/1/2011. Bell Post Hill & Belmont programs conclude on the 28/1/2011. Transport to and from excursions is in the form of Bus or Walking. The School Holiday Program operates on a 1:15 ratio when Centre Based and 1:8 ratio on excursions and 1:5 for Water based Excursions. When enrolling online you will be required to complete a consent authorisation form, which will be sent to you upon receipt of your enrolment. This form must be signed and returned to us by Monday 20 December 2010.

Privacy & Agreement
Privacy:	Council is collecting this information for the purpose of registering your child for the School Holiday Program. This information will be used for administration purposes and to contact you in the event of an emergency, but will not be disclosed to any other party except as required by law. If you fail to provide this information, the registration may not be processed. This information will also be used to provide you with details of our next School Holiday Program. You may access this information by contacting the School Holiday Program on 5272 4805.
Parent/Guardian Declaration:	I, the undersigned: 1. I agree to pay for all of the days my child is successfully enrolled, regardless of whether my child actually attends the School Holiday Program, this includes changed holiday plans, illness, changed care arrangements etc, as per our Enrolment and Fee Collection Policy. 2. I agree that I and any authorised contact person will present photo identification each time my child/ren are collected. 3. I the undersigned, have checked and give permission for my child/ren to participate in the Excursions and Centre Based activities as outlined on the days I have selected on this online booking form. 4. I authorise staff, in the event of an accident or illness, to obtain all necessary medical/ambulance assistance and treatment for my child and agree to meet any expenses attached to such treatment. 5. I authorise staff to apply sunscreen and insect repellent to my child when required. 6. I agree that the City of Greater Geelong and their Officers are to be free and clear of all responsibility whatsoever for accident, illness, theft of clothing or valuables during my child’s participation on any of the activities involved on the program. 7. I understand that electronic equipment (game boy, mobile phones, etc) are not permitted at the Holiday Program. 8. I give permission for my child to travel on chartered bus for excursion purposes and go on local walks to playgrounds etc accompanied by staff 9. I give permission for photographs to be taken for Quality Assurance purposes. I understand photographs will not be released or used for any other purpose without my prior consent. 10. The information I have provided on this form is correct.
Agreement:	If you accept all of the Agreements, please approve them as a group by selecting the YES option below. If you do not agree to the Agreements in their entirety without modification, then click the Cancel button to discontinue your registration. Yes I Agree   By selecting "YES I Agree", I am entering into, and agreeing to be bound by all of the Agreements.