School Holiday Care Enrolment Form

Child's Details

First Name

Last Name

Child's Residential Address

Unit Number

Street Address

Suburb/Town

Postcode

Is postal address different from residential address?

The postal address is the primary postal address for all Latrobe City correspondence.

Unit Number

Street Address

Suburb/Town

Postcode

Child's date of birth (mm/dd/yyyy)

Child's gender

Male

Female

Child's Centrelink reference number (CRN)

Please specify the main language spoken at home?

Is this child Aboriginal or Torres Strait Islander

What is the cultural background of this child?

Child's Medical Information

Child's Medicare number

Name of child's doctor or medical service?

Address of child's doctor or medical service

Unit Number

Street Address

Suburb/Town

Postcode

Phone number of child's doctor or medical service

Please detail any diagnosed healthcare needs of this child

Please detail any allergies of this child

Please detail any dietary restrictions for this child

Is this child at risk of anaphylaxis?

Please upload any medical management plan, anaphylaxis medical management plan or risk minimisation plan to be followed for any healthcare need, condition or allergy.

Upload Management Plan

Upload Management Plan 2

Parent 1 Details

First Name

Last Name

Parent/Guardian 1 date of birth (mm/dd/yyyy)

Parent/Guardian 1 email

Parent/Guardian 1 contact number

Parent/Guardian 1 residential address

Unit Number

Street Address

Suburb/Town

Postcode

Parent/Guardian 1 Centrelink reference number (CRN)

Parent/Guardian 1 cultural background

Parent 2 details

First Name

Last Name

Parent/Guardian 2 date of birth (mm/dd/yyyy)

Parent/Guardian 2 email

Parent/Guardian 2 contact number

Same residential address as parent 1

Parent/Guardian 2 residential address

Unit Number

Street Address

Suburb/Town

Postcode

Parent/Guardian 2 Centrelink reference number (CRN)

Parent/Guardian 2 cultural background

Authorisations

I give permission for my child to be photograph for the purposes of advertising and promotional material

I give permission for my child to have sunscreen applied as per Latrobe City Council's Sun Smart Policy

I acknowledge that personal electronic devices are not permitted in the program

Emergency Contact 1

Emergency contact must be someone other than Parent or Guardian

First Name

Last Name

Best Contact Number

Residential Address

Unit Number

Street Address

Suburb/Town

Postcode

Emergency Contact 1 Areas of authority

to be notified of an emergency involving this child if parent can not be immediately contacted

who has been given permission to collect the child

can authorise an educator to take the child outside of the service premises

Emergency Contact 2

Emergency contact must be someone other than Parent or Guardian

First Name

Last Name

Best Contact Number

Residential Address

Unit Number

Street Address

Suburb/Town

Postcode

Emergency Contact 2 Areas of authority

to be notified of an emergency involving this child if parent can not be immediately contacted

who has been given permission to collect the child

can authorise an educator to take the child outside of the service premises

Court orders, parenting orders and parenting plans

Court/Parenting Order Details

Please provide details of any court orders, parenting orders or plans relating to authorities, duties, responsibilities in relation to the child or access to the child.

Court Order Details - Residential

Please provide details of any court orders relating to the child's residence or the child's contact with a parent or another person.

Upload court order information

Upload court order additional information

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