Custodial Statement. Are there any custodial arrangements concerning your child? If YES, please give details of any custodial arrangements or court orders (a copy of any court order is required) Person/s who cannot pick up your child: Name: Name: Name: Name: Additional Emergency Contacts (also able to pick up child):
Custodial Statement. Are there any custodial arrangements concerning your child? Yes □ No □ If YES, please give details of any custodial arrangements or court orders (a copy of any court order is required) Person/s who cannot pick up your child: Please note: if you are naming the Father or Mother of the child we cannot prevent them from collecting or visiting unless we have a custody order on file. Name: Name: Relationship to the child: Relationship to the child: Enrolment Details: Date of Enrolment: Date of Entry: Date of Exit: Days Enrolled: Monday Tuesday Wednesday Thursday Friday Times Enrolled: Total number of hours: Please Note: 20 Hours ECE is for up to six hours per day, up to 20 hours per week and there must be no compulsory fees when a child is receiving 20 Hours ECE funding. For 20 Hours ECE fill out boxes below with the hours attested e.g. 6 hours 20 Hours ECE at this service Total number of hours: 20 Hours ECE at another service Total number of hours: Parent/Guardian Signature: Date: / / 20 Hours ECE Attestation: Is your child receiving 20 Hours ECE for up to six hours per day, 20 hours per week at this service? Tick One Yes No Is your child receiving 20 Hours ECE at any other services? Tick One Yes No If yes to either or both of the above, please sign to confirm that:
Custodial Statement. Are there any custodial arrangements concerning your child? If YES, please give details of any custodial arrangements or court orders (a copy of any court order is required) Person/s who cannot pick up your child: Name: Name: Name: Name: Child’s doctor: Name: Phone: Name of medical centre: Health Illness/allergies: Is your child up-to-date with immunisations? Tick One Yes No (Please provide verification of all immunisations) For staff: Immunisation records sighted and details recorded: Tick One Yes No Medicine
Custodial Statement. Are there any custodial arrangements concerning your child? If YES, please give details of any custodial arrangements or court orders (a copy of any court order is required) Person/s who cannot pick up your child: :❑ Yes :❑ No Name: Name: Name: Name: ♦ Enrolment Details: Date of Enrolment: / / Date of entry: / / Date of Exit: / / Days Enrolled: Monday Tuesday Wednesday Thursday Friday TIMES ENROLLED Mornings – 2 year olds only Limited spaces apply 8:15am-1pm Total number of hours
Custodial Statement. Do both parents have day-to-day care of your child? YES/NO If “NO” are there any parenting orders or custodial arrangements concerning your child? Please advise the supervisor of any such orders or arrangements. (Please note, a court order needs to be sighted and a copy held on file for us to prohibit a parent or guardian from collecting his/her child.) Name of person who is NOT allowed to collect my child: Name Court Order is on file YES/NO In which programme are you enrolling your child? Holiday programme YES/NO Casual Booking YES/NO (Please note that casual bookings require at least one day’s notice) Permanent booking YES/NO (Indicate days required below) Monday Tuesday Wednesday Thursday Friday Mornings Start Time Afternoons Finish Time The school your child attends Room Number Child’s doctor Surgery Phone In the event of a medical emergency, I understand my child will be taken to hospital in an ambulance if necessary. The parents (in the first instance) or an approved contact person will be notified immediately. All medical costs incurred are at the child’s principal caregiver’s expense. I give permission for the use of Arnica cream to be applied to bumps and bruises. YES/NO I give permission for the staff to apply sunblock to my child’s skin. YES/NO I give permission for my child to be given basic First Aid treatment by the staff. YES/NO If my child has a fever, rash, sticky eyes, diarrhoea or vomiting s/he will be kept at home until the symptoms are gone. If your child shows such symptoms at the programme, GASP staff will notify you and you will arrange to have your child picked up as soon as possible.
Custodial Statement. Are there any custodial arrangements concerning your child? If YES, please give details of any custodial arrangements or court orders (a copy of any court order is required) Person/s who cannot pick up your child: Name: Name: Name: Name: Health & Wellbeing: Does your child have any medical conditions, illnesses, food allergies, dislikes, fears, special needs that Rosy Cheeks staff should be aware of? Tick One Yes No If YES, please provide details: Is your child up-to-date with immunisations? Tick One Yes No (Please provide verification of all immunisations) For staff: Immunisation records sighted and details recorded: Tick One Yes No Child’s Doctor: Name: Phone: Name of medical centre: Medicine:
Custodial Statement. Are there any custodial arrangements concerning your child? If YES, please give details of any custodial arrangements or court orders (a copy of any court order is required) Person/s who cannot pick up your child: Name: Name: Name: Name: Child’s doctor: Name: Phone: Name of medical centre: Any changes to this form must be signed and dated by the parent/guardian. Health Illness/allergies: Is your child up-to-date with immunisations? Copy to be provided. Tick One Yes No For staff: Immunisation records sighted and details recorded: Tick One Yes No Medicine
Custodial Statement. Are there any custodial arrangements concerning your child? If YES, please give details of any custodial arrangements or court orders (a copy of any court order is required) Person/s who cannot pick up your child: Name: Name: Name: Name: Health Illness/allergies: Is your child up-to-date with immunisations? Tick One Yes No (Please provide verification of all immunisations) To what age? For staff: Immunisation records sighted and details recorded: Tick One Yes No In the event of an accident or emergency involving my child, I/we authorize the Centre to seek such advice or treatment as it deems necessary in the best interests of my/our child, while making all efforts to contact a parent/guardian Yes No Medicine
Custodial Statement. Are there any custodial arrangements concerning your child? If YES, please give details of any custodial arrangements or court orders (a copy of any court order is required) Person/s who cannot pick up your child: Name: Name: Name: Name: Child’s doctor: Name: Phone: Name of medical centre: Illness/allergies: Health Is your child up-to-date with immunisations? Tick One Yes No (Please provide verification of all immunisations) For staff: Immunisation records sighted and details recorded: Tick One Yes No Does your child require a special diet? If so please give details: In an emergency may we obtain medical help for your child? Medicine I give permission for the non-medical staff at Xxxx Street Early Learning Centre to administer medication to my child. Parent/Guardian Signature: Date: / /
Custodial Statement. Are there any custodial arrangements concerning your child? If YES, please give details of any custodial arrangements or court orders (a copy of any court order is required) Person/s who cannot pick up your child: Name: Name: Name: Name: Doctor: Name: Phone: Address: Medical Centre: Health Illness/allergies (please specify) Is your child up-to-date with immunisations? Circle one Yes No (Please provide verification of all immunisations) If No, will you be immunising your child in the future? For staff: Immunisation records sighted and details recorded: Circle one Yes No Individual needs: Disabilities / health problems (please specify) (Information may be made available to Public Health when required)
