1.

(First) CHILD DETAILS

Mother’s Name ____
SURNAME ___________________________ ____
CRN _______________________ Date of Birth
CRN
GIVEN NAME(S) __________________________
Mother’s place of employment
DATE OF BIRTH ___ / ___ / ______ ____
YEAR LEVEL ___________________ Mother’s contact phone number ____
(H) ___ (B) ____
(Second) CHILD DETAILS (Mob) ____
Email __
SURNAME ___________________________
Father’s Name __
CRN _______________________
Date of Birth
GIVEN NAME(S) __________________________ Father’s place of employment
DATE OF BIRTH ___ / ___ / ______ ____
Father’s contact phone number ____
YEAR LEVEL ___________________
(H) ___ (B) ____
(Mobile) ____
(Third) CHILD DETAILS
Email __
SURNAME ___________________________
Who is responsible for the account? __
CRN _______________________
____
GIVEN NAME(S) __________________________ 5. STARTING DATE
DATE OF BIRTH ___ / ___ / ______
Before School Care
YEAR LEVEL ___________________
After School Care
2. ADDRESS
6. EMERGENCY CONTACT DETAILS
Post code: (Other than primary caregiver/s)

1. Name _____
3. BOOKINGS Relationship to child: _____
Which days will the child attend? [ Please tick] PH: (H) ___ (B) _____
(Mobile) _____
Before school care After school care Can this person collect your child from the program:
Yes
Monday Monday No
2 .Name_______________________________
Tuesday Tuesday Relationship to child: _____

Wednesday Wednesday PH: (H) ___ (B) _____

(Mobile) _____
Thursday Thursday
Can this person collect your child from the program:
Friday Friday
Yes
Casual Casual No

7. COLLECTION OF CHILDREN
*Any Changes of attendances please submit
these in writing to OSHC. Are there special custody arrangements?
Yes
No

If yes please provide a copy of all relevant documentation

4. PARENT DETAILS
8. MEDICAL DETAILS
Doctor’s Name
Doctor’s Contact Number
Doctor’s Address
Medicare Number
Do you have Ambulance Subscription Yes/No
If yes – Ambulance Subscription Number
________________________________
Relevant Medical History
Does your child have special needs?
e.g ADHD, wheelchair access
Please list all allergies, disabilities, asthma, and illnesses
Is your child on medication?
If Yes give details __
9. COUNTRY OF BIRTH
Primary Language ______________________
Other Language/s ______________________
Requires Interpreter?
Yes
No
To ensure priority of access according to Commonwealth
Government requirements, please indicate which applies
to your care requirements.
 Special circumstances
 Work or Study related
 Parent/Child disability
 Respite
10. FEES
CHILD CARE BENEFITS [CCMS]
To apply phone the FAO (Family Assistance Office)
on 136150 or center link on 136150.
Please quote CRN: 407 279 616J
Fees are calculated weekly and the discount is applied to
your weekly account or in a lump sum quarterly.
11. OPERATING HOURS
____
____
Before School Care: 6.45 – 8.45am
__
____ After School Care: 3.30 – 6.15pm
____
13. PARENT/GUARDIAN DECLARATION
I consent to the child/ren named above:
 Participating in the Before and or After School Care
Program run by the Patterson Lakes Primary School
Council;
 Being transported from their school to the location
where the Program is conducted from time to time;
 Participating in walks or excursions from time to time,
which will take place away from the location where
__ the program is conducted; and
__  Appearing in photos taken and displayed for the
__ purposes of promoting the Program
I agree that neither the Patterson Lakes Primary School
___ Council nor its employees, or the Department of
Education and Training and its employees will be liable for
___ any loss of or damage to property or for any personal
injury whosoever caused or of whatsoever nature which
___
may be sustained by the child/ren named above whilst
Yes/No participating in the program or in any activities in
connection with the program.
________
Where it is impracticable to communicate with me, I
authorise the person in charge of the Program from time
to time to obtain all medical assistance and pass on
relevant medical information as may be deemed
necessary for the child/ren, and I agree to meet any
expenses incurred in respect of such medical assistance.
I agree that I have received and read the parent handbook
and agree to the terms and conditions that are included in
the handbook.
I agree to pay all fees for participation in the program. I
acknowledge that the program concludes at 6.15 pm. In
the event that the child/ren is/are collected after this time,
I agree to pay the late fee which is applicable for every 15
minutes, or part thereof, after 6.15 pm.”
Signature of Parent/Guardian:
Date: ___/___/___
OFFICE USE ONLY
Date enrolment form received ___/___/___
All details completed yes / no
Places available  Parent notified 
Waiting list  Parent notified 
Supervisors
Signature ____________________________