School Holiday Program Enrolment

If you have any difficulty filling out the form, please come to our center, our friendly staff will help you!

Child's Details

Child First Name

Child Last Name

Gender

Date of Birth

Aboriginal or Torres Strait Islander?

Child's Street Address

Child's Suburb

Child State

Child's Postcode

Allergies?

Yes No

Anaphylaxis

Yes No

Asthma?

Yes No

Diabetes

Yes No

Dietary Restrictions

Medical Conditions / Healthcare Needs

Yes No

Please Provide details of any Medical Condition/s, Allergies, Healthcare needs and/or Dietary Restrictions below (Please Clearly Specify Restrictions

Is there any other information that would assist staff caring for your child?

If your child has any Medical Documents /Plans (Anaphylaxis Management Plans), Please Upload Below

Restricted Access Details

Is There Any Court Order /Restraining Orders/ Family Law Orders involved with this child?

Yes No

Details of the Court Order

Parent/Guardian Details

Parent/ Guardian #1 Full Legal Name

Does Parent/Guardian #1 live at the same address as child?

Yes No

Please Provide Address of Parent/Guardian #1 (if different from the child)

Email Address of Parent/Guardian #1

Mobile of Parent/Guardian #1

Parent/ Guardian #2 Full Legal Name

Does Parent/Guardian #2 live at the same address as child?

Yes No

Please Provide Address of Parent/Guardian #2 (if different from the child)

Email Address of Parent/Guardian #2

Mobile of Parent/Guardian #2

Emergency Contact Details

To be contacted in case Parent/ Guardian #1 or #2 cannot be contacted

Emergency Contact Full Name

Street Address

Mobile Number

Does this Emergency Contact have lawful authority from you, to:

Collect this child from the service

Yes No

Request or Permit the administration of medication to this child

Yes No

Consent to medical treatment of this child?

Yes No

Authorise staff to take children outside of the service premise?

Yes No

Details of Additional people who can collect this child:

Person #1 Full Name

Person #1 Address

Person #1 Mobile Number

Person #2 Full Name

Person #2 Address

Person #2 Mobile Number

Details of Medical Practitioner:

Name of Family Doctor/Medical Practice

Medical Practice Contact Number

Medical Practice Address

Child's Medicare Number (If Available)

Details of Cultural Background:

Cultural Background of Child/Parents

Languages spoken at home

Claiming CCS (Child Care Subsidy):

To claim the child care subsidy, this section must be completed. If no information is completed here, you will be charged the full fee of our program.

Parent's Name for Child Care Subsidy

Parent's Gender

Male Female

Parent's Date of Birth

Parent's CRN Number

Child's CRN Number

Parent Declarations:

Please Sign these Declarations by filling in your details below

Is Parent #1 or #2 the one who is signing these "Parent Declarations"

Parent #1 Parent #2 Other

If answered OTHER, please provide your Name, Telephone and Email

I Authorise Springvale Indoor Sports to:

Take my child on Regular Pre-Planned Excursions (Back of the Centre 50m away from building) Call Medical Services and Transport my child to Hospital in case of Illness/Accident (I agree to pay all cost associated) Administer Medication (if required)

Springvale Indoor Sports

If you have any difficulty filling out the form, please come to our center, our friendly staff will help you!

Child's Details

Restricted Access Details

Parent/Guardian Details

Emergency Contact Details

Does this Emergency Contact have lawful authority from you, to:

Details of Additional people who can collect this child:

Details of Medical Practitioner:

Details of Cultural Background:

Claiming CCS (Child Care Subsidy):

Parent Declarations:

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