School Holiday Program Enrolment Application Form

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	Question Time
	School Holiday Program Enrolment - Summer 2009
	Submission to Proposed Local Law
	Volunteers

School Holiday Program
Enrolment Application Form - Spring 2008

Parent/Guardian must complete this form.
Fields marked with need to be completed
Centerlink
Centrelink Reference Number for this family:
This enrolment application will not be processed unless a Centrelink Reference Number is clearly indicated here. Call the Family Assistance office on 13 61 50 to get your number if you do not have it. If you DO NOT intend to claim Child Care Benefit as reduced fees, we still need your Centrelink Reference Number to comply with government reporting requirements.
Confidential Child Details
First Child Details
Child Name:
D.O.B (dd/mm/yyyy):
Year level in 2008:
School Attended :
Gender:		Male Female
Allergies:
Asthma:
Medical Condition:
Medication:
Does this child have any additional or specific needs that we should be aware of?		Yes No
Does this child have an aide at school?		Yes No
Does this child need an aide whilst at Holiday Program?		Yes No
Does this child have any special transport requirements?		Yes No
Can sunscreen be applied to this child during the program?		Yes No

Second Child Details
Child Name:
D.O.B (dd/mm/yyyy):
Year level in 2008:
School Attended :
Gender:		Male Female
Allergies:
Asthma:
Medical Condition:
Medication:
Does this child have any additional or specific needs that we should be aware of?		Yes No
Does this child have an aide at school?		Yes No
Does this child need an aide whilst at Holiday Program?		Yes No
Does this child have any special transport requirements?		Yes No
Can sunscreen be applied to this child during the program?		Yes No

Third Child Details
Child Name:
D.O.B (dd/mm/yyyy):
Year level in 2008:
School Attended :
Gender:		Male Female
Allergies:
Asthma:
Medical Condition:
Medication:
Does this child have any additional or specific needs that we should be aware of?		Yes No
Does this child have an aide at school?		Yes No
Does this child need an aide whilst at Holiday Program?		Yes No
Does this child have any special transport requirements?		Yes No
Can sunscreen be applied to this child during the program?		Yes No

Fourth Child Details
Child Name:
D.O.B (dd/mm/yyyy):
Year level in 2008:
School Attended :
Gender:		Male Female
Allergies:
Asthma:
Medical Condition:
Medication:
Does this child have any additional or specific needs that we should be aware of?		Yes No
Does this child have an aide at school?		Yes No
Does this child need an aide whilst at Holiday Program?		Yes No
Does this child have any special transport requirements?		Yes No
Can sunscreen be applied to this child during the program?		Yes No

Parent / Guardian Details (This must be the person whose reference number is listed above)
Main Contact
Full Name:
Relationship to Child:
Date of Birth
Home Phone:
Work Phone:
Mobile:
Email:
Street Address:
Suburb:
Postcode:
Do you give permission for School Holiday Program to contact you by SMS message on your mobile phone?		Yes No
Is this person authorised to collect your children?		Yes No

Are you responsible for payment?		Yes No

Additional Adult Contact Details
Please nominate 2 adults (other than the parent / guardian listed above) to contact in case of emergency:

Adult 1
Full Name:
Relationship to Child:
Home Phone:
Work Phone:
Mobile:
Email:
Is this person authorised to collect your children?		Yes No

Adult 2
Full Name:
Relationship to Child:
Home Phone:
Work Phone:
Mobile:
Email:
Is this person authorised to collect your children?		Yes No

Background Information

Are you an Aboriginal or Torres Strait Islander family?			Yes No
Are there any court orders that effect any of the children listed on this enrolment application?			Yes No
Do you give your permission for your child/ren to be photographed during the program?			Yes No
Do you give your permission for your child/ren to watch PG rated movies under the supervision of SHP Staff during the program?			Yes No
Has your child/ren attended the CoGG School Holiday Program before?			Yes No
What is the primary language spoken at home?
How many of your children will be attending OTHER approved childcare services during the school holidays? (Eg. Long Day Care, Family Day Care.)


Booking Information
Please select your 1st preference venue:	Belmont Bell Post Newtown Ocean Grove Leopold

If there are not sufficient places at this centre, would you like to be placed at another centre?		Yes No
Please select your 2nd preference venue:	Belmont Bell Post Newtown Ocean Grove Leopold

Please write your child's name and select the days you would like them to attend the school holiday club.

Name of Child	Mon 22/9	Tue 23/9	Wed 24/9	Thu 25/9	Fri 26/9	Mon 29/9	Tue 30/9	Wed 1/10	Thu 2/10	Fri 3/10

Child Care Benefit (CCB)
Child Care Benefit
1. I would like to claim Child Care Benefit (CCB) as reduced fees. 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.
2. I would like to claim CCB as a lump sum.
3: I do not want to claim Child Care Benefit.
Have you advised and registered with the Family Assistance Office that your child/ren will be attending the CoGG School Holiday Program?			Yes No

Additional Comments
Additional Comments:

Privacy & Agreement
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 5227 0805. 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 2. I give permission for my child/ren to participate in the excursions and centre based activities organised for the days my child will be attending. 3. 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. 4. I authorise staff to apply sunscreen and insect repellant to my child. 5. 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. 6. I understand that electronic equipment (game boy, mobile phones, etc) are not permitted at the Holiday Program. 7. I give permission for my child to travel on chartered bus for excursion purposes. 8. I give permission for photographs to be taken for Quality Assurance purposes. 9. The information I have provided on this form is correct. IMPORTANT - Please note that you will be charged for the days you book, rather than the days you actually use. In the event that you do not use your booked days (due to changed holiday plans, sickness, etc), you are still required to pay for your booking. If you accept all of the Agreements, please sign 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 Clear button to discontinue your registration.
YES
By selecting YES clicking the I Agree button, I am entering into, and agreeing to be bound by all of the Agreements.