School Holiday ‘Vacation Care’ Program Enrolment Form

School Holiday Program Enrolment Form

Child's Details:
Child's Legal Name*
First Last
Name Child is known as (if different)
Child's Gender*
Child's Date of Birth*

DD
MM
YYYY
Does this child identify as Aboriginal or Torres Strait Islander?
Child's Street Address*
Child's Suburb*
Child's State*
Child's Postcode*
Child's Age*
It appears this child is 5 years old or younger. To attend the school holiday program children must be attending primary school in the same calendar year of their attendance. (This is a rule from the Department of Education and is part of our licence to operate an 'Education and Care Service'. We have no scope to amend this rule.) Please check the box below to confirm that this child is able to attend.*
- This child is attending primary school in the same calendar year that they're attending the School Holiday Program.
Please note: Unfortunately, if this child is not attending primary school in the same calendar year we cannot accept them in the program. Please come back as of the January school holidays in the calendar year that they will be starting school. We look forward to seeing you then. Thank you.
What is the swimming ability of this child?*
Does this child have any allergies?*
Does this child have anaphylaxis?*
Does this child have asthma?*
Does this child have diabetes?*
Does this child have any dietary restrictions?*
Does this child have any other medical conditions or healthcare needs?*
You have indicated that your child has one of the medical conditions above that require a medical management plan. Please check the boxes below to confirm that relevant medication/s and action plan/s will be brought with the child to the program every day.*
- I understand that I must bring my child's medication and medical management/action plan and hand them in to reception every day that my child attends the program.
*
- I understand that it is my responsibility to make sure that any medication is within its use-by date, and that any medical management/action plan is within 12 months old.
*
- I understand that my child will not be able to join the program without these items being handed in to reception at the beginning of every day that my child attends the program. (Please note: It is a requirement under National Law and Regulations that children who have known medical conditions not be permitted to join a care program without these items being present and accounted for. If you forget your medical items, we have NO CHOICE but to ask you to go home and return when you have them. Thank you.)
*
- I understand that it is my responsibility to notify the centre in writing should there be any change to my child's medical condition/s.
Please provide details of any medical condition/s, healthcare needs and/or dietary restrictions.*
(Note: If you have indicated that your child has allergies and anaphylaxis, please make sure you specify which reaction they have to each allergen. eg. Allergic to latex, gets mild skin rash. Anaphylaxis to peanuts.)
Please provide details of measures that need to be taken to minimise the risks associated with this child's medical condition/s. (eg. Are there any activities that should be avoided? Are there times when extra supervision is required? etc.)*
Are there any special instructions about how communication is to take place between Healthways, the child and the parents in regards to this child's medical condition/s?*
Please provide details.*
What is this child's immunisation status?*
Please note: You don't need to supply a copy of your child's health record to the School Holiday Program. The response to this question is self-declared.
Please provide details of 'incomplete' immunisation status*
Is there any other information that would assist with the care of this child? (eg. Personality considerations, behavioural considerations, techniques for inclusion, etc.)*
Please provide details*
Restricted Access Details:
Is there a court order/ family law order/ restraining order pertaining to this child?*
Details of court order/ family law order/ restraining order:*
Parent/Guardian Details:
Parent/Guardian #1's Legal Name*
First Last
Name Parent/Guardian #1 is known as (if different)
Does Parent/Guardian #1 have the same address as the Child?*
Parent/Guardian #1's Street Address*
Parent/Guardian #1's Suburb*
Parent/Guardian #1's State*
Parent/Guardian #1's Post Code*
Parent/Guardian #1's Email*
This is the email address that your invoices and theme day reminders will be sent to.
Enter Email Confirm Email
Parent/Guardian #1's Preferred Phone Number*
Parent/Guardian #1's Secondary Phone Number
Parent/Guardian #2's Legal Name (if applicable)
First Last
Name Parent/Guardian #2 is known as (if different)
Does Parent/Guardian #2 have the same address as the Child?
Parent/Guardian #2's Street Address*
Parent/Guardian #2's Suburb*
Parent/Guardian #2's State*
Parent/Guardian #2's Post Code*
Parent/Guardian #2's Email
Enter Email Confirm Email
Parent/Guardian #2's Preferred Phone Number
Parent/Guardian #2's Secondary Phone Number
Emergency Contact Details:
To be contacted in case of emergency if parent/guardian #1 and #2 cannot be contacted.
Emergency Contact Name
First Last
Emergency Contact Street Address
Emergency Contact Suburb
Emergency Contact Post Code
Emergency Contact Preferred Phone Number
Emergency Contact Secondary Phone Number
Does this Emergency Contact have lawful authority from you, to:
• Collect this child from the service?*
• Request or permit the administration of medication to this child?*
• Authorise the taking of this child outside the premises of the service by a staff member of the service?*
• Consent to the medical treatment of this child?*
Details of additional people who can collect this child:
Collection Person #1 Name
First Last
Collection Person #1 Street Address
Collection Person #1 Suburb
Collection Person #1 Post Code
Collection Person #1 Preferred Phone Number
Collection Person #1 Secondary Phone Number
Collection Person #2 Name
First Last
Collection Person #2 Street Address
Collection Person #2 Suburb
Collection Person #2 Post Code
Collection Person #2 Preferred Phone Number
Collection Person #2 Secondary Phone Number
Details of Medical Practitioner:
Name of your family doctor/medical practice
Medical Practice Address
Medical Practice Suburb
Medical Practice Post Code
Medical Practice Phone Number
Child’s medicare number (if available)
Details of Cultural Background:
Language spoken at home
Cultural background of child and/or parents
Claiming 'Child Care Subsidy':
To claim the 'Child Care Subsidy' this section must be completed. At the completion of the holiday program period your upfront fees will be reconciled according to your rate of applicable 'Child Care Subsidy'. If no information is completed here, you will be charged the full fee.
If you don't have this information to hand right now, you can leave this section blank and email through your Child Care Subsidy information to healthways@healthways.com.au and we will update your record.
Parent's Name for Child Care Subsidy
First Last
Parent's Gender
Parent's Date of Birth

DD
MM
YYYY
Parent's CRN
Child's CRN
Parent/Guardian Declaration:
Authorisation for regular excursion to Mont Albert Reserve:*
This information is required for your child to participate in the School Holiday Program’s outdoor activities.
- I give consent for my child to participate in the outdoor activities (weather permitting), held as part of the School Holiday Program.
  I acknowledge that I am aware that:
  • Outdoor activities are held at Mont Albert Reserve (Cnr Braemar St and Dunloe Ave), 140 metres away from Healthways where there is an oval, basketball courts, playground equipment, and grass/tree areas.
  • Children will be off-site for approx. 1 hour per day.
  • Children will walk to Mont Albert Reserve.
  • Activities at Mont Albert Reserve include physical education activities such as: games, athletics, ball skills, sports, team events, etc.
  • The number of children attending Mont Albert Reserve can be 10-60 depending on when the activities are scheduled during morning activity rotations and how many children are attending the program on any given day.
  • Ratio of educators to children is a maximum of 1:15, as prescribed in the National Law & National Regulations. There may also be times where extra staff members who are rostered in the School Holiday Program and/or volunteers are allocated to provide extra supervision.
  • A risk assessment has been prepared and is available to be viewed at Healthways.
Authorisation for child to be taken out of the School Holiday Program to participate in another activity at Healthways if applicable. This information is required for your child to be taken to other activities that you've booked them in to at the centre (eg. Swimming lessons, Teen Gym classes):*
We do ask all parents to tick this authorisation just in case it ever applies to you. Note: If you would like your child taken to another activity, please tell staff in the morning when you drop off so that we know. Thank you.
- By booking my child in to the School Holiday Program and also into another activity at Healthways Recreation Centre that occurs at the same time, I give permission for my child to be signed out of the School Holiday Program by staff, taken to their activity, participate in their activity, be collected by staff at the end of their activity and signed back in to the School Holiday Program.
Authorisation to make necessary medical arrangements:*
- In the event of illness or accident, I authorise the person in charge to make arrangements for any necessary medical, ambulance and/or hospital treatment that my child may require. I authorise for my child to be transported by an ambulance service. I agree to pay all necessary fees incurred on behalf of my child in the case of an emergency. I authorise for my child to be transported by private car if necessary.
General procedures:*
- I understand that we must walk our child into Healthways and sign the appropriate forms and that we do the same when picking them up. I understand that a $1.00/minute fee will apply if I drop off early or pick up late. The earliest drop off time and latest pick up time is listed in my booking. I understand that any fees will be charged to my credit card at the end of the holidays.
Please sign these declarations by filling in your details below:
Is it Parent/Guardian #1 who is signing these 'Parent Declarations'?*
My name is*
First Last
My phone number is:*
My secondary phone number is:
My email address is:*
Enter Email Confirm Email
BEFORE CLICKING SUBMIT...
Please review your booking details above and ensure they are correct. When you click 'Submit' your payment and booking will be processed. Particularly check the days you have enrolled in! As per our refund policy, in the event that you need to cancel (or change days) there is an amount that is non-refundable.
AFTER CLICKING SUBMIT...
Please click 'Submit' only ONCE and look for the CONFIRMATION message. When you click 'Submit' you will see either a confirmation message or there will be parts of your form highlighted red to indicate information that is not filled in correctly. Your booking is not confirmed until a confirmation message appears! If you can still read this sentence after clicking 'Submit', you have not submitted the form correctly. Please review your form and try again.

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School Holiday Program Enrolment Form

Child's Details:

Restricted Access Details:

Parent/Guardian Details:

Emergency Contact Details:

Details of additional people who can collect this child:

Details of Medical Practitioner:

Details of Cultural Background:

Claiming 'Child Care Subsidy':

Parent/Guardian Declaration:

BEFORE CLICKING SUBMIT...

AFTER CLICKING SUBMIT...