Once completed, please save and return this form to Hotham Day Care [email protected]
Hotham Day Care
Kids Ski & Ride School, Big D
PO Box 140, Bright Vic 3741
P: 5759 4451
[email protected]
Dear Families,
As of January 1st 2016, the “No Jab, No Play” legislation in Victoria has come into effect, we now require all children to be immunised and
provide evidence of immunisation prior to commencement at Hotham Daycare.
An Immunisation History Statement from the Australian Childhood Immunisation Register can be used as evidence of up to date
vaccination. An Immunisation Status Certificate from a medical doctor or a local council immunisation service may also be used.
Immunisation History Statements are available on request at any time by contacting Medicare:
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By telephone on 1800 653 809 – have your Medicare number ready
By email on [email protected]
Online at www.humanservices.gov.au/customer/services/medicare/medicare-online-accounts
Online at my.gov.au
In person at your local Medicare service centre.
Immunisation details
I will provide my child’s immunisation history:
DCC-01(Rev2016-02)
via email
In person at Hotham
Daycare - Enrolment form
Once completed, please save and return this form to Hotham Day Care [email protected]
Immunisation details
I will provide my child’s immunisation history:
via email and attached to this form
Date(s) that Day Care is needed
Dates Attending
In person at Hotham
Today’s Date
Child Information
First Name
Preferred name (if applicable)
Date of Birth
Home Address
Mountain Accommodation Details
Last Name
Gender
Male
Language spoken at home
Female
Suburb
State
Postal Code
Parent / Guardian 1 Information
First Name
Home Address
Last Name
Suburb
Phone (mobile)
Does the Child live with the above Parent / Guardian
Email
No
Yes
Postal Code
Parent / Guardian 2 Information
First Name
Home Address
Last Name
Suburb
Phone (mobile)
Does the Child live with the above Parent / Guardian
Email
No
Yes
Postal Code
Emergency Contact
In the event of an occasion (accident, injury, trauma or illness, to your child) and we’re unable to contact the Parent(s)/Guardian(s).
We’re authorized to contact the listed Emergency Contacts. Emergency contacts are not required to be located on the mountain
Emergency 1 Contact Must be different to parents guardians
First Name
Last Name
Home Address
Phone (mobile)
Suburb
Relationship to the Child
Emergency 2 Contact
Postal Code
Must be different to parents guardians
First Name
Home Address
Last Name
Suburb
Phone (mobile)
Relationship to the Child
Postal Code
Medical and Health Information Please see declaration of consent to medical treatment below
In the event that medical treatment is required for your child, do you consent to the use of the Hotham Medical Centre?
Yes
No
Hotham Medical Centre P: 03 5759 3551
Your registered medical practitioner/medical service
Name
Phone
Address
Introduction to Ski Programs
Will your child be participating in one of our introduction to ski programs? Yes
No – if no complete move to next section
Permission for a qualified ski instructor registered with Mount Hotham Skiing Company to remove your child from the premises of
Hotham Day Care for the purpose of ski lessons: Yes
No
Permission for Hotham Day Care staff to apply sunscreen to your child prior to their ski lessons: Yes
No
DCC-01(Rev2016-02)
Court orders relating to the child
Is there a court orders relating to the powers and responsibilities of the parents in relation to the child or access to the child
No – if no move on to Signature/Declaration Section
Yes – If yes follow the steps below
Bring the original or certified court order/s for staff to see and copy to attach to this document If these orders:
1.
2.
Change the powers of a parent/guardian to:
a. authorise the taking of the child outside the service by a staff member of the service;
b. Consent to the medical treatment of the child;
c. request or permit the administration of medication to the child;
d. collect the child, and/or
Give these powers to someone else, please describe these changes and provide the contact details of any person given
these powers.
Signatures/Declaration
Definitions
Lawful authority
“lawful authority” refers to your consent of the nominated emergency contact people to provide Hotham Day Care staff permission to:
I. Administer medication;
Ii. Apply medical and emergency treatment;
Iii. Collect your child on your behalf.
A court order, such as under the family law act, may take away the authority of a parent or guardian to do something, or may give it to another
person.
Parents
All parents have powers and responsibilities in relation to their children which can only be changed by a court order. The children’s services
regulations 2009 refer to these powers and responsibilities as “lawfulAuthority”. It is not affected by the relationship between the parents, such as
whether or not they have lived together or are married.
Guardians
A guardian of a child also has lawful authority. A legal guardian is given lawful authority by a court order. The
Definition of “guardian” under the children’s service act 1986 also covers situations where a child does not live with his or her parents and there are
no court orders. In these cases, the guardian is the person the children lives with who has day-to-day care and controls the child.
Declaration and consent to emergency and medical treatment
By signing below I attest that I have lawful authority of the child referred to on this enrolment form. I do declare that the information provide is true
and accurate.
In the case of emergency Hotham day care advises that you consider ambulance coverage in the case of a medical emergency while in our care;
Upon signing this document , you declare:
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that the information provided is true and correct and undertake to immediately inform Hotham Day Care of any change to this information;
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you agree to collect or make arrangements for the collection of the child referred to in this enrolment form if she/he becomes unwell at the
service;
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you consent to Hotham Day Care staff seeking, or where appropriate, administering, such emergency medical treatment as is reasonably
necessary;
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In the case where a medical emergency occurs, you agree to reimburse any necessary expenses incurred by Hotham Day Care;
Parent/Guardian 1 Name and Signature
Date
Parent/Guardian 2 Name and Signature
Date
DCC-01(Rev2016-02)
Daycare – Routine form
Details of your child’s normal daily routine: Please provide as much information as possible
Child Information
First Name
Last Name
Preferred name
Age
Languages spoken at home
Allergies and dietary requirements
Allergies
No
Yes, specify
Anaphylaxis
No
Yes, if yes please bring a copy of child’s medication and anaphylaxis plan, specify
Asthma
No
Yes, if yes please bring a copy of child’s medication and asthma plan
Dietary requirements
No
Yes, specify
Medical and Special Conditions
Medical or special condition
No
Yes, specify
Physical or developmental special condition
No
Yes, specify
Under 12 months
List of foods tried
Food form
Puree only
Some finger and mashed food, specify
Other notes
Bottles (please make sure all bottles, formulas etc. are labelled)
Does your child require a bottle or milk while at Daycare
Type of bottle
Full cream milk
No
Breast milk
Bottle
Formula milk
Approx. bottle Time: Bottle 1
Amount/Instructions, specify
Approx. bottle Time: Bottle 2
Amount/Instructions, specify
Approx. bottle Time: Bottle 3
Amount/Instructions, specify
Approx. bottle Time: Bottle 4
Amount/Instructions, specify
Cup of milk
Soya milk
Other, specify
Other notes
Rest Time
Does your child require rest or sleep while at Daycare
Rest/Comfort Items
No
No
Yes,
Cot
Mattress
Yes (blanket, dummy, teddy, wrap), specify
Sleep 1 time:
Sleep 3 time:
Sleep 2 time:
Sleep 4 time:
Other notes
Toileting
Toileting
Nappies
Toilet Training (needs assistance and reminding)
Toilet Trained
Rest time nappy
Other notes
Other notes, please provide any other information to help us assisting your child to enjoy their day
Permission for Daycare members to:
Take photos of your child’s day (for internal use only)
No
Yes
Participate in face painting
No
Yes
To apply sunscreen prior to their private ski lesson
No
Yes
DCC-01(Rev2016-02)