Child's Confidential Record - Family Day Care

Please complete this form for each child you are enrolling. Windermere FDC must collect the information in this form to meet regulatory requirements.

If you need help completing this form? please contact us on 1300 946 337.

The documents you will require to complete this enrolment are:

Action plan - if your child has a diagnosed medical condition or allergy.
Court order documents - if applicable.
Imunisation documents.
Medicare card.
Additional needs supporting documents - if applicable.

Thank you and we look forward to having your child in our care!

How did you hear about us? *

Are you currently accessing Windermere Family Day Care? *

YesNo, but I have in the last 12 monthsNo, I haven't

Do you know the educator who will care for your child? *

YesNo

Educator name *

Is your child related to the educator? *

YesNo

How is your child related to the educator? *

Are you or is any other parent or legal guardian of this child a registered Family Day Care educator? *

YesNo

Child's Customer Reference Number (CRN) *

Is your child of Aboriginal or Torres Strait Islander heritage? *

NoYes, AboriginalYes, Torres Strait IslanderYes, both Aboriginal and Torres Islander

Expected start date *

What type of care do you wish to book? *

Permanent careCasual careSchool holiday care

Monday drop off time *

Monday pick up time *

Tuesday drop off time *

Tuesday pick up time *

Wednesday drop off time *

Wednesday pick up time *

Thursday drop off time *

Thursday pick up time *

Friday drop off time *

Friday pick up time *

Saturday drop off time *

Saturday pick up time *

Sunday drop off time *

Sunday pick up time *

1. Child's details

Given name(s) *

Surname *

Date of birth *

Country of birth *

Gender *

MaleFemale

Child's home address

Address *

Suburb *

Postcode *

Language(s) spoken in your child's home *

Cultural background(if applicable)

2. Your details

Who is considered a parent?

By law, the definition of a 'parent' includes:

a biological parent
a person with parental responsibility for the child under a decision or order of a court

Who is not considered a parent?

A person cannot be considered a parent if they have not obtained parental responsibility for the child under a decision or order of a court. This includes:

a parent's partner (non-biological parent)
a family member
another carer

The person completing this form must be the parent/ guardian with the CRN linked to the child.

I am completing this form as a parent/ guardian of the child. The details I provided below will be my own. *

Given name(s) *

Surname *

Date of birth *

What is your relationship to your child? *

MotherFatherOther

Does your child live with you? *

YesNo

Your contact details

Please provide as many contact details as possible. At least one phone number is reuired.

Home phone

Mobile phone *

Email address *

Work details

Are you working? *

YesNo

Occupation *

Workplace name

Workplace address

Street Name & Number

Suburb

Postcode

Work phone

Language & cultural details

What is the main language you speak? *

Country of birth *

Cultural background(if applicable)

Do you need an interpreter? *

YesNo

My contact preference is *

EmailPhoneMobile

Child Care Subsidy

In order for the service to provide Child Care Subsidy (CCS), the person applying for CCS must provide their Customer Reference Number (CRN) and the CRN of the child.

Are you the parent applying for the Child Care Subsidy? *

YesNo

Your Customer Reference Number (CRN) *

Does the child have another parent? *

YesNo

Parent/ Guardian 2 details

Given name(s) *

Surname *

Email address *

Home phone

Mobile phone *

Country of birth *

Date of birth *

Occupation *

Does parent 2 live with you?

YesNo

Does parent 2 live with your child?

YesNo

Street Name & Number

Suburb

Postcode

Cultural background *(if applicable)

Language spoken at home *

My contact preference *

EmailPhone Mobile

3. Court orders

Are there any:

Court orders, parenting orders or parenting plans concerning the powers, duties and responsibilities, or authorities of any person in relation to the child or access to the child?
Details of court orders relating to the child's residence or the child's contact with a parent or other person?

YesNo

Please upload copies of these documents *

Browse

You must provide the educator with updated or amended court orders, parenting orders or parenting plans if they are changed.

Your child will not be able to attend family day care if you do not provided us with a copy of the current document(s).

If these documents change or if any of the above become applicable, I will provide updated versions to Windermere and/or my child's educator *

4. Authorised contacts other than a parent

This section is for you to authorise other people to act on your behalf in certain circumstances.

You cannot include those who are already listed as parents / guardian 1 and 2
You must provide two (2) authorised contacts
You cannot authorise your Windermere Family Day Care Educator to be an authorised contact.
Only included people who are over 16 years of age time.

Contact 1

Full name *

Relationship to your child *

Address *

Suburb *

Postcode *

Please fill in at least one phone number.

Work phone

Mobile phone *

Please tick the boxes below to confirm the level of authorisation you give to this person. This authorised contact can: *

Collect/Deliver child to/from the serviceGive permission to authorise an Educator to take the child outside the Education and Care premisesConsent to medical treatment for childPermit transportation of child by an ambulance serviceGive permission to authorise the education and care service to transport the child or arrange transportation of the childRequest/permit medication to be given to childIf the parent/guardians cannot be contacted this person should be notified of any accident, injury, trauma or illness involving the child

Contact 2

Full name *

Relationship to your child *

Address *

Suburb *

Postcode *

Please fill in at least one phone number.

Work phone

Mobile phone *

Please tick the boxes below to confirm the level of authorisation you give to this person. This authorised contact can: *

Add another contact?

YesNo

Contact 3

Full name *

Relationship to your child *

Address *

Suburb *

Postcode *

Please fill in at least one phone number.

Work phone

Mobile phone *

Please tick the boxes below to confirm the level of authorisation you give to this person. This authorised contact can: *

Add another contact?

YesNo

Contact 4

Full name *

Relationship to your child *

Address *

Work phone

Suburb *

Postcode *

Please fill in at least one phone number.

Mobile phone *

Please tick the boxes below to confirm the level of authorisation you give to this person. This authorised contact can: *

Add another contact?

YesNo

Contact 5

Full name *

Address *

Suburb *

Postcode *

Please fill in at least one phone number.

Work phone

Mobile phone *

Relationship to your child *

Please tick the boxes below to confirm the level of authorisation you give to this person. This authorised contact can: *

5. Medicare Details

Does your child have a Medicare number? *

YesNo

Medicare number *

Medicare reference number *

6. Maternal & Child Health Centre Details

Name of medical service *

Doctor's name

Doctor's phone number *

Doctor's address *

Suburb *

Postcode *

Do you have ambulance cover? *

YesNo

7. Medical conditions

Does your child have any medical conditions? *

YesNo

Does your child have any diagnosed allergies? *

YesNo

Please list your child's allergies *

Does your child have any dietary restrictions (including cultural)? *

YesNo

Please list your child's dietary restrictions *

My child has been: *

diagnosed as being at risk of anaphylaxisprescribed an adrenaline auto-injector device (AAID)diagnosed with asthmadiagnosed with epilepsydiagnosed with diabetesdiagnosed with eczemadiagnosed with another condition

I agree to have my child's medical details displayed within the service. *

YesNot applicable

*This is a legislative requirement for Family Day Care

Please upload your child's current Action Plan (within the last 12 months) for their condition. Your child's doctor can provide this plan.

It is important that you ask for a copy of the Guidelines for your child's medical condition. This will help you understand how the educator will support your child.

The educator will also complete a Risk Management & Communication Plan with you before your child commences care.

Action Plan *

Browse

8. Additional needs

Windermere is committed to providing an environment that values and respects the needs of all children to fully participate.

Does your child have any additional needs? *

YesNo

Is your child linked to other professional services? *

YesNo

Example include a paediatrician, an early intervention service, therapists, Preschool Field Officers and an Inclusions Support Facilitator.

Name of professional service *

Please provide any supporting documentation

Browse

9. Immunisation and health

By law, your child must be immunised before they can start Family Day Care.

You must provide an Immunisation History Statement (available from MyGov or Medicare).

Documents we cannot accept

The child's Health Record (blue book)
Health & Development Record (green book)
Overseas immunisation documents
Homeopatic immunisation documents
Statutory declarations
Conscientious objection and vaccination objection on non-medical grounds
Certificates from your doctor

*Windermere Family Day Care do not site health records.

Copy of your child's immunisation documents *

Browse

10. Filming and photography consent

A parent's consent is required before images and recordings can be taken of their child.

Do you agree to audio, video and still images and power point presentations taken by staff/educators to be used within the service for programming use? *

YesNo

Do you agree to audio, video and still images being taken by staff/educators/parents/guardians of other children where my child may also be in the photo? *

YesNo

Do you agree to audio, video and still images being taken by staff/educators in the education and care service home or playgroup venue and displayed? *

YesNo

Do you agree to audio, video and still images being taken for use in newspaper, websites (including Windermere’s Website), marketing and other external publications? *

YesNo

If we require consent to use audio, video and still images that are not covered by the points above, we will ask you for separate consent to suit the situation.

11. Privacy

Our Privacy Policy is about how we handle your personal information.

We collect personal information from you when it is reasonably necessary for a business purpose. That means we collect it to supply you with the services and/or products you have asked for and to provide you with the best possible service.

Other reasons we collect personal information are to:

Understand you and how we can meet your needs now and in the future
Develop or evaluate services and products
Make ads more relevant to you
Manage our business
Comply with our legal obligations

We may collect personal information like your name, address, date of birth, gender, occupation, location, contact details or payment details depending on the activity you undertake with us. There are a few different ways we collect this information.

For more information please see our Privacy Policy.

I have read and agree to Windermere's Privacy Policy *

12. Sunscreen

Educators will supervise children to apply sunscreen in accordance with SunSmart Victoria Guidelines.

For more information about how we use sunscreen to protect your child, please ask your educator for a copy of the Weather Protection Guidelines.

I authorise educators to apply the sunscreen I have provided for my child

I authorise educators to apply sunscreen they provided if I have not provided sunscreen for my child

13. Declaration and consent

I, the parent completing this form

Declare that the information in my Child's Confidential Record is true and correct and undertake to immediately inform the educator at the service in the event of any change to this information *

Understand that during an emergency or drill where evacuation is necessary that the child may need to leave the service under the direction and supervision of the educator *

Authorise the Person with Management and Control, Nominated Supervisors or educator at the service to seek necessary medical treatment for my child from a registered medical practitioner, hospital, dental or ambulance that includes the transportation of my child by an ambulance from the service in the event of an emergency. I agree that all associated medical expenses will be my responsibility *

Declare that the information in this enrolment form is true and correct and identifies all allergies and medical conditions known to me at this time *

Agree to complete new enrolment form/s in the event of any change to this information and if required by Windermere *

Agree to collect or make arrangements for the collection of the child referred to in this enrolmentform if he/she becomes unwell at the service *

Understand that my/our written permission will be sought for excursions outside the service *

Consent to my/our child/ren being bathed when attending to immediate hygiene needs *

Consent for Staff/Educators/Program Coordinators to inspect your child’s hair for head lice as deemed necessary during the year *

Consent to the use of band aids on my/our child/ren if required *

Agree to read and approve the complying written agreement as required by the department ofeducation and training *

Agree to my/our child/ren going on outings outside the Family Day Care Educator’s home and understand that all reasonable care will be taken in the supervision of my child *

Permit my/our child/ren to travel in a vehicle registered with the Family Day Care Service, with a registered Educator or Coordination Unit staff *

Please sign here *

Clear

Name *

Date *

Save and Complete Later