JumpStart Educare Enrolement Form

JumpStart Educare Online
Enrolment Form

Note: The information gathered on this form will be sent to Jumpstart Educare via email. Jumpstart will have a copy of your form printed out and waiting for you at the office. You will need to double check the details and sign the form regarding consent by law.

Childs Name:

Adress:

Post Code:

Home Phone:

Work Place & Work Phone:

Mobile:

Fax:

E-mail:

Emergency Contact Name & Phone:

Date Of Birth :

Place In Family :

Sex :

Male Female

People Who Are Authorized To Collect My Child :

People Who Are forbidden by Law to have Access or Access with Conditions :

I will be bringing in Child Custody Details

Yes
No

To Which Ethnic Group do you belong?

NZ Moari
NZ European/ Pakeha
Pacific Island
Asian
Other

If Other Please Specify :

Iwi Affiliation :

Car Registration :

Booking Times

Session	Mon	Tues	Wed	Thurs	Fri
Morning
Afternoon
Full Day

HEALTH INFORMATION

Family Doctor :

Practice Name :

Doctors Phone :

Health Problems/ allergies :

Immunisation certificated sighted date :

Immunisation Completed :

6 Weeks (triple)
3 Months (triple + polio)
5 Months (triple + polio)
15 Months (measles)
MMR
Hepatitis B

Information You Feel The Team Leader Should Know: (toileting/sleep/food routines; dislikes; special fears; needs etc) :

Is Your Child Enrolled At Any Other Childhood Service :

Yes
No

If Yes , State Times :

I expressly acknoledge that enters the Educare Centre at my own risk and that although proper care will be exercise at all times, the Centre cannot accept responsibility for misadventures.

PRE-VISIT

Prefered Pre-Visit dates

Visit 1 :

Visit 2 :

Visit 3

Information & Notification

I have read and understand the following points and agree to :

1) Adhere to the sickness policy given to me at enrolement or to pick up my child at the discretion of the Supervisor if he/she is infectious or sick.

2) Notify the centre if my child is to be absent or if I require a change in hours and pay any retaining fee necessary to secure my booking.

3) Ensure and understand that my child will not be released from the centre, unless notification for anyone other than those listed will pick up my child.

4) As per the regulations HS28, set out in appendix three of the early childhood regulations 2008. The required authorisation will be given to parents prior to administering of any medications.

5) Pay fees to a maximum of two weeks as outlined in the fees policy recieved on enrolement, plus give one weeks notice before withdrawing my child from the centre and pay any outstanding fees.

6) Understand that throughout the year, observations and evaluations on my child's progress will be done.

7) From time to time, for centre use only, photographs of my child will be taken.

8) Parent evenings are held throughout the year and I will endeavour to attend.

9) Understand that if I have any complaints or concerns regarding services, I will diorect these to the staff member concerned or if necessary take further steps in accordance with the centres parent complaint policy as displayed on the centres noticeboards.

10) From time to time, children may go on supervised walks from the centre. Do you give permission? Yes / No

11) Please provide the following information:

Name Of Child :

Date Of Birth :

Is the child recieving Free ECE at any other service(s)?

Please confirm the daily total time (hours and minutes) of Free ECE claimed at all services the child is enrolled at on the chart below.

EFFECTIVE DATE	MON	TUES	WED	THURS	FRI	SAT	SUN	TOTAL
Free at this service
Free at another service
Total

The hours listed in the above table will require your initals on arival to the centre

Note: A maximum of 6 hours per day and 20 hours per week per child.

I confirm that:

The child named above does not receive more than 20 hours Free ECE per week across all services.
I will immediately notify all sefvices where the child receives Free ECE of any changes to the information provided above.
I have read and understood the information in this form and confiem that the information provided by me is true and correct.

Name :

Relationship to Child :

This declaration will require your signiture on arrival to the centre