KNOX PARK PRIMARY SCHOOL
April Vacation Care Program
PARENT APPLICATION FORM
The following document will be used for enrolment into Knox Park Primary School’s Out of School Hours Care
Vacation care program in addition to parent and child/ren’s enrolment forms. Please make sure the
information in correct and updated when necessary.
Child/ren’s Information (please print)
Name:……………………………………………………………………………………….. D.O.B………………………………………………………………
Grade……………………………………… School Attended……………………………………………………………………………………………….
Child’s Address: ………………………………………………………………………………………………………………………………………………….
Name:……………………………………………………………………………………….. D.O.B………………………………………………………………
Grade……………………………………… School Attended……………………………………………………………………………………………….
Child’s Address: ………………………………………………………………………………………………………………………………………………….
Name:……………………………………………………………………………………….. D.O.B………………………………………………………………
Grade……………………………………… School Attended……………………………………………………………………………………………….
Child’s Address: ………………………………………………………………………………………………………………………………………………….
Has your child/ren attended a Children’s Service before? If so, what type?
…………………………………………………………………………………………………………………………………………………………………………...
What activities does your child/ren enjoy participating in?
……………………………………………………………………………………………………………………………………………………………………………
Parent/Guardian Information
Mother/Guardian’s Name:……………………………………………………………………………… D.O.B…………………………………………
Home address (if different from child’s)………………………………………………………………………………………………………………
Work Address:…………………………………………………………………………………………………………………………………………………….
Telephone/s (H)..................................... (W)………………………………. (Mobile)……………………………………………………….
Email: …………………………………………………………………………………………………………………………………………………………………
Father/Guardian’s Name:……………………………………………………………………………… D.O.B…………………………………………
Home address (if different from child’s)………………………………………………………………………………………………………………
Work Address:…………………………………………………………………………………………………………………………………………………….
Telephone/s (H)..................................... (W)………………………………. (Mobile)……………………………………………………….
Email:…………………………………………………………………………………………………………………………………………………………………..
Other person’s to be notified or are authorised to collect your child
Name:………………………………………………………………………………………………………………………………………………………………….
Address:………………………………………………………………………………………………………………………………………………………………
Telephone/s (H)..................................... (W)………………………………. (Mobile)……………………………………………………….
Name:………………………………………………………………………………………………………………………………………………………………….
Address:………………………………………………………………………………………………………………………………………………………………
Telephone/s (H)..................................... (W)………………………………. (Mobile)……………………………………………………….
Medical InformationDoctors Name:………………………………………………………………Phone………………………………………………………………………….
Address:……………………………………………………………………………………………………………………………………………………………
…
Medicare Number……………………………………………………………………………………………….Ambulance subscriber Yes/No
Medical Information or special needs (asthma, allergies, dietry restrictions, medications – include
Management Plans)
……………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………
(all medication to be administered must follow the Medication Policy and must be noted in the medication book and signed)
Is your child/ren’s immunisation up to date?
Yes
No (please circle)
Does the service have a copy of the Immunisation Certificate?
Yes
No (please circle)
Do you receive or have you applied for Childcare Benefit?
Yes
No (please circle)
Is the Childcare benefit being claimed as reduced fees or as a Family Assistance Office lump sum?
……………………………………………………………………………………………………………………………………………………………………………
Court Orders
Is there a current custody order in place? …………………………………………………………………………………………………………
If yes, the original document must be sighted by a staff member of the service and a copy be provided.
Booking InformationFamilies MUST book their child/ren into each program. Booked days not attended will be charged at the
session rate and an absence recorded. Bookings are on a term basis. Please tick the days you wish to attend.
Monday
Tuesday
Wednesday
Thursday
Friday
07/04/14
08/04/14
09/04/14
10/04/14
11/04/14
Week
1
14/04/14
15/04/14
16/04/14
Week
2
17/04/14
CENTRE
CLOSED
DeclarationI/We agree that neither Knox Park Primary Council, nor it’s officers and servants, will be liable for any
damage or injury to my child/ren that may be incurred in any activity involved in the program.
I/We authorise OSHC staff, in the event of any illness or accident, to obtain on my behalf, any such medical
assistance or treatment as deemed necessary and to meet the cost of such treatment.
……………………………………………………………………………………………………
Signature
………………………………………………
Date