Enrolment Form Cranley

Draft

Enrolment Form

Enrolment Form
I would like to enrol my child to *

Cranley House (Eastwood) Ashgrove House (Prospect)
Child Information
Name *

First Name Last Name
Nickname
Usually Called

Address *

Date of Birth *

- Month - Day Year
Child CRN
Customer Reference Number (CRN) from the Family Assistance Office (www.familyassist.gov.au or 136150) Note: Not necessary for Kindergarten or Preschools.
Country of Birth
Religion
Is the child Aboriginal and/or Torres Strait islander origin? (please tick)

No, not Aboriginal or Torres Strait Islander Yes, Aboriginal and Torres Strait Islander Yes, Aboriginal Yes, Torres Strait Islander

Address *

Address *

Other Person/s Authorisations
Other Person/s Authorisations

Please list below the details of those people who you have authorised as emergency contacts for the child. This list may be amended at any time. In the event that the parents or guardians cannot be contacted the person/s listed below with authority will be contacted regarding collecting the child, in even of an emergency involving the child, consent or medical treatment or the administration of medication, or to authorise an Educator to take the child outside of the Service premises.
Contact #1
Name

First Name Last Name

Address

Home Phone Number

- Area Code Phone Number
Work Phone Number

- Area Code Phone Number
Mobile Phone Number

- Area Code Phone Number
Relationship to the child
Court Orders in Relation to the Child
Are there any:
- Court orders, parenting orders or parenting plans relating relating to the powers, duties, responsibilities or authorities of any person in relation to the child or access to the child?
- other court orders relating to the child's residence or the child's contact with a parent or other person?
*

Yes (attach original order/s) No (go to the next section)
Attach File

Medical Service Address

Medicare Number
Expiry Date

- Month - Day Year
Ambulance Subscription Number
Expiry Date

- Month - Day Year
Is the child currently attending or has previously attended:

Counsellor/Psychologist Speech Therapy Occupational Therapy Dietitian Pediatrician Specialist Other

Child's Medical Information
ANAPHYLAXIS
Has the child been diagnosed as at risk of anaphylaxis? *

Yes No
Does your child have a auto injection device (e.g. EpiPen or Anapen)? *

Yes No
If Yes, please supply the service a device with a valid expiry date and a copy of of Anaphylaxis Action and/or management Plan.
ALLERGIES
Does your child have any allergies? *

Yes No
if Yes, please provide details of any allergies and any management plan/s or risk minimisation plan/s to be followed with respect to the specific health care need/s or medical condition/s. Attach a copy of any plan/s or additional pages if necessary.
Attach file

Enrolment Form