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Happy Feet Childcare Centre

123 Fun Lane Southport QLD 4215

ABN: 1234567890

07 55940 519
admin@centrename.com.au
https://www.Centre.com.au

Learn more about childcare

Waitlist Application

Financial Guardian

Child Information

Health Information

Emergency Contacts

Finish

Financial Guardian Details

You must be registered with CentreLink to receive childcare benefits for this child.

Surname

Your Surname is required.

First name

Your first name is required.

Date of Birth

Your date of birth is required.

CRN

Please provide valid CRN.

Street

Please provide a street.

Suburb

Please provide a suburb.

State

Please provide a State.

Postal Code

Please provide valid Post Code.

Home Phone

Valid home phone is required.

Mobile Phone

Valid mobile phone is required.

Email Address

@

Please provide valid email address.

Nationality

Relationship to Child

Your Relationship to Child is required.

Occupation

Employer

Work Phone

Cultural Background

I agree to keep my fees paid up to date and understand that my child’s position will be in jeopardy if my fees are not kept up to date.

Partner Details

Surname

Your Surname is required.

First name

Your first name is required.

Date of Birth

Your date of birth is required.

CRN

Please provide valid CRN.

Copy primary address details

Street

Please provide a street.

Suburb

Please provide a suburb.

State

Please select a state.

Postal Code

Please provide valid Post Code.

Home Phone

Valid home phone is required.

Mobile Phone

Valid mobile phone is required.

Email Address

@

Please provide valid email address.

Nationality

Relationship to Child

Your Relationship to Child is required.

Occupation

Employer

Work Phone

Cultural Background

Child Details

Surname

Child's Surname is required.

First name

Child's first name is required.

Middle name

Child's Middlename is required.

Preferred Name

Date of Birth

Child's date of birth is required.

CRN

Please provide valid CRN.

Gender

Please select a gender.

Diagnosed Disabilities

No Yes

Indigenous Status

Please select a Indigenous Status.

Faith

Phone(Child)

Main Language Spoken in Home

Valid Main Language Spoken at Home is required.

Cultural Background

Permissions

Do you consent to your child being taken by ambulance in an emergency

No Yes

Do you consent for sunscreen to be applied while in the care of this service

No Yes

Booking Details

Required Start Date

Child's start date required.

Before School Care Bookings

After School Care Bookings

Vacational School Care Bookings

Special Considerations

Does Child live with Guardian?

No Yes

Are there any court orders in place?

No Yes

Upload Copy of the court order

Choose a file

Consent for photos of your child to be used for observation reporting

No Yes

Consent for photos of your child to be used social media used by the Centre

No Yes

Upload photo [Optional] Preview/ Set

Photo Preview

Health Information

Doctor's Name

Name is required.

Doctor's Phone

Phone is required.

Street

Please provide street.

Suburb

Please provide Suburb.

State

Please provide State.

Postal Code

Please provide valid Post Code.

Please provide post code.

Medicare Number

Medicare Number is required.

Number on Card

Number on Card is required.

Name of Private Health Fund

Please provide valid Name of Private Health Fund

Is your child fully Immunised

No Yes

Upload Copy of Immunisation

Choose a file

Does your child take any medication

No Yes

Upload Medical Management Plan

Choose a file

Comments for Medication:

Please upload Medical Management Plan or provide Comments for Medication

Does your child have asthma

No Yes

Upload Asthma Management Plan

Choose a file

Comments for Asthma:

Please upload Asthma Management Plan or provide Comments for Asthma

Is your child diagnosed as At Risk of Anaphylaxis:

No Yes

Upload Anaphylaxis Management Plan

Choose a file

Expiry Date on Anaphylaxis Pen

Your Child1AnaphylaxisExpiryDate is required.

Comments for Anaphylaxis:

Please upload Anaphylaxis Management Plan or provide Comments and expiry date for Anaphylaxis

Dietary Requirements

No Yes

Comment:

Has your child been diagnosed with a disability

No Yes

Comment:

Does your child have any allergies

No Yes

Comment:

Does your child have any known fears

No Yes

Comment:

Does your child have any additional needs

No Yes

Comment:

Emergency Contacts

Contact 1

Surname

First Name

Street

Please provide street.

Suburb

Please provide Suburb.

State

Please provide State.

Postal Code

Please provide valid Post Code.

Please provide post code.

Phone Number 1

Please provide valid phone number.

Phone Number 2

Please provide valid phone number.

Relationship to Child

Authorised to Sign Child In/Out of Centre

No Yes

Can give authorisation for Medical Treatment or Administration of Medication

No Yes

Can give consent for excursions / incursions

No Yes

Can give authorisation for Transport of Child or Arrange Transport of Child

No Yes

Contact 2

Surname

First Name

Street

Please provide street.

Suburb

Please provide Suburb.

State

Please provide State.

Postal Code

Please provide valid Post Code.

Please provide post code.

Phone Number 1

Please provide valid phone number.

Phone Number 2

Please provide valid phone number.

Relationship to Child

Authorised to Sign Child In/Out of Centre

No Yes

Can give authorisation for Medical Treatment or Administration of Medication

No Yes

Can give consent for excursions / incursions

No Yes

Can give authorisation for Transport of Child or Arrange Transport of Child

No Yes

Contact 3

Surname

First Name

Street

Please provide street.

Suburb

Please provide Suburb.

State

Please provide State.

Postal Code

Please provide valid Post Code.

Please provide post code.

Phone Number 1

Please provide valid phone number.

Phone Number 2

Please provide valid phone number.

Relationship to Child

Authorised to Sign Child In/Out of Centre

No Yes

Can give authorisation for Medical Treatment or Administration of Medication

No Yes

Can give consent for excursions / incursions

No Yes

Can give authorisation for Transport of Child or Arrange Transport of Child

No Yes

Submit Enrolment Form

How did you hear about us?

Parent Agreement

By submitting I agree to keep my fees paid up to date, as per Payment of Fees Policy, and understand that my child’s position at the Service will be in jeopardy if my fees are not kept up to date. I understand that all booked days are paid for even when my child is absent due to sickness or on holidays.

Privacy Disclaimer

We acknowledge and respect the privacy of its clients. The enrolment information that is collected assists us to meet our legislative obligations and to provide the best level of education and care for your child. By completing this form, you have consented to this information being collected. The information will be used by educators/staff members and relevant government authorities. You have the right to access and alter personal information concerning yourself or your child in accordance with the Privacy Act 1988 and our Privacy and Confidentiality Policy.

I confirm the information provided on this enrolment form to be true and correct.