Enroll Form

Child Full Name:

Parent’s Full Name:

Date of Enrolment:

Date of Entry:

Date of Exit:

Documents required
Birth Certificate/ Passport
Immunisation Record
Photo ID of Parent
Others	(Please Specify)

7- 9 Wookey Lane
Kumeu, Auckland 0810
09 412 8081
021 119 5148, 021 0910 4333
[email protected]
www.kumeuchildcare.co.nz

Enrolment Agreement Form

Child’s details:

Child’s official surname or family name:

Child’s official given name:

Child’s official other names / middle names:
(please separate names with a comma):

Name your child is known by / preferred name:

Surname / family name:

Given name:

Copy of official identity verification document* collected by staff:

New Zealand birth certificate

Foreign birth certificate

New Zealand passport

Foreign passport

Other

Staff initials:

Child’s date of birth:

Male
Female

Child’s ethnic origin/s:

Iwi your child belongs to:

Language/s spoken at home:

Child’s primary residential address:

Post Code:

Privacy Statement:

We are collecting personal information on this enrolment form for the purposes of providing early childhood education for your child.

We will use and disclose your child’s information only in accordance with the Privacy Act 1993. Under that Act you have the right to access and request correction of any personal information we hold about you or your child.

Details about your child’s identity will be shared with the Ministry of Education so that it can allocate a national student number for your child. This unique identifier will be used for research, statistics, funding, and the measurement of educational outcomes.

You can find more information about national student numbers at: eli.education.govt.nz

* Information about acceptable identity verification documents is available online at: eli.education.govt.nz

The Ministry recommends that all services keep a copy of the identity verification document of each child who is enrolled at the service.

Parents / Guardians:
Mr/Mrs/Miss/Ms:	Mr/Mrs/Miss/Ms:
1. Given names:	2. Given names:
Surname / family name:	Surname / family name:
Address:	Address:
Post Code:	Post Code:
Phone (Home):	Phone (Home):
Phone (Work):	Phone (Work):
Phone (Mobile):	Phone (Mobile):
Email:	Email:
Relationship to child:	Relationship to child:

Mr/Mrs/Miss/Ms:	Mr/Mrs/Miss/Ms:
1. Given names:	2. Given names:
Surname / family name:	Surname / family name:
Address:	Address:
Post Code:	Post Code:
Phone (Home):	Phone (Home):
Phone (Work):	Phone (Work):
Phone (Mobile):	Phone (Mobile):
Email:	Email:
Relationship to child:	Relationship to child:

Additional Emergency Contacts (also able to pick up child):
Mr/Mrs/Miss/Ms:	Mr/Mrs/Miss/Ms:
1. Given names:	2. Given names:
Surname / family name:	Surname / family name:
Address:	Address:
Post Code:	Post Code:
Phone (Home):	Phone (Home):
Phone (Work):	Phone (Work):
Phone (Mobile):	Phone (Mobile):
Email:	Email:
Relationship to child:	Relationship to child:

Mr/Mrs/Miss/Ms:	Mr/Mrs/Miss/Ms:
1. Given names:	2. Given names:
Surname / family name:	Surname / family name:
Address:	Address:
Post Code:	Post Code:
Phone (Home):	Phone (Home):
Phone (Work):	Phone (Work):
Phone (Mobile):	Phone (Mobile):
Email:	Email:
Relationship to child:	Relationship to child:

Custodial Statement
Are there any custodial arrangements concerning your child?
If YES, please give details of any custodial arrangements or court orders (a copy of any court order is required)
Person/s who cannot pick up your child:
Name:	Name:
Name:	Name:

Note: No Child will be given permission to leave the Centre unless the person collecting the child is noted on this form. If a person who is not on this from a written letter by the parent must be presented to the Centre manager.

Health:
Child’s Doctor:	Doctor’s Phone:
Doctor’s Address:
In the unlikely event of a medical emergency, I understand my child will be given basic first Aid treatment by the educator and if necessary taken to the hospital in an ambulance. Parents or a contact person will be notified immediately. Any Child with a fever, rash, sticky eyes, diarrhoea or vomiting is required to stay at home until 48 hours after symptoms settle. Disclosures:
I am aware of the health related policies have been informed of this Y / N I give permission for my child’s head to be checked for lice by the Centre Manager. Y / N I am aware that in the case of my child having head lice, she/he may be asked to stay home until treated. Y / N I give permission to apply NZ approved sun block, insect repellent and/ or zinc to my child. Y / N
Health: Does your child have any specific dietary requirements/illness/allergies: ( Please specify)

Is your child up-to-date with immunisations?	Tick One YesNo
(Please provide verification of all immunisations)
For staff: Immunisation records sighted and details recorded:	Tick One YesNo

Medicine
Category (i) Medicines
A category (i) medicine is a non-prescription preparation (such as arnica cream, savlon, antiseptic liquid, insect bite treatment) that is not ingested, used for the ‘first aid’ treatment of minor injuries and provided by the service and kept in the first aid cabinet. Note: The service must provide specific information about the category (i) preparations that will be used.
Do you approve category (i) medicines to be used on your child?	Tick One YesNo
Name/s of specific category (i) medicines that can be used on my child
*	*
*	*
Parent/Guardian Signature:	Date:

Category (ii) Medicines
Category (ii) medicines are prescription (such as antibiotics, eye/ear drops etc) or non-prescription (such as paracetamol liquid, cough syrup etc) medicine that is used for a specific period of time to treat a specific condition or symptom, provided by a parent for the use of that child only or, in relation to Rongoa Māori (Māori plant medicines), that is prepared by other adults at the service.
I acknowledge that written authority from a parent is to be given at the beginning of each day a category (ii) medicine is to be administered, detailing what (name of medicine), how (method and dose), and when (time or specific symptoms/circumstances) medicine is to be given.
Parent/Guardian Signature:	Date:

Category (iii) Medicines
To be filled in if your child requires medication as part of an individual health plan, for example for an on-going condition such as asthma or eczema etc and is for the use of that child only.
For staff: Individual health plan sighted and a copy taken:	Tick One YesNo
Name of medicine:
Method and dose of medicine:
When does the medicine need to be taken: (State time or specific symptoms)

Parent/Guardian Signature:	Date:

Enrolment Details:
Date of Enrolment:	Date of Entry:	Date of Exit:

20 Hours ECE Attestation:
1. Is your child receiving 20 Hours ECE for up to six hours per day, 20 hours per week at this service?
	Tick One YesNo
2. Is your child receiving 20 Hours ECE at any other services?	Tick One YesNo
If yes to either or both of the above, please sign to confirm that:
* Your child does not receive more than 20 hours of 20 Hours ECE per week across all services.
* Your authorise the Ministry of Education to make enquiries regarding the information provided in the Enrolment Agreement Form, if deemed necessary and to the extent necessary to make decisions about your child’s eligibility for 20 Hours ECE.
* You consent to the early childhood education service providing relevant information to the Ministry of Education, and to other early childhood education services your child is enrolled at, about the information contained in this box.
Parent/Guardian Signature:	Date:

Dual Enrolment Declaration
I hereby declare that my child is/is not enrolled at another early childhood institution at the same times that he/she is enrolled at [insert name of service].
Parent/Guardian Signature:	Date:

Permission to go on trips including driving on the motor way.
I give permission for my child to go on trips including driving on the motor way. Kumeu Childcare will ensure the vehicles that are used to transport children to and from the trip complies with New Zealand road laws including a current WOF & Registration.

Declaration

I give Kumeu Childcare responsibility to transport my child to and from childcare. I understand and accept the responsibilities of Kumeu Childcare. I agree that in the unlikely event of an accident it is not Kumeu Childcare’s responsibility provided Kumeu Childcare meets the requirements listed above.

Parent Name:

Parent Sign:

Relationship to Child:

Terms & Conditions

Enrolment: One week fees must be paid prior to enrolment day. This covers your first week and leaves you one week in advance. It is mandatory to keep your account one week in advance.

Payment: Fees are to be paid by direct debit only. Accounts that are in arrears without prior arrangement will incur a late payment penalty of $5 per week for every week your account is in arrears. Failure to meet your payment obligations will result in collection costs being charged to your account.

Late Pick Up: We understand at times you may have an unforeseen circumstance that forces you to run late. Where we can assist we will however we are not licenced to stay open past 5.30pm. Late pick up may result in a fee $10 for every 15 minutes (or part thereof) being charged to your account. This is at the Centre Managers discretion.

Holidays: Centre will be closed during statutory holiday. Statutory Holiday are charged in full except for any hours attested as 20 Hours ECE. You are entitled to 3 weeks annual leave at a reduced rate of 50% off your normal fee during the year. You need to ensure the Centre is notified in writing 3 week prior to your leave date. Failure to do so will result in full fees being charged to your account.

Statutory Holiday/ Terms Breaks: This enrolment agreement is inclusive of school term breaks. This service is closed on Statutory Holidays

Absence: If your child is absent due to sickness or any other reason (apart from planned holidays above) you are still required to pay the full fee for the day of absence.

I have read and agree to the above terms and conditions
Parent/Guardian Signature:	Date:

Sibling Discount

We provide a sibling discount of 10% which will be for the younger child.

Changes to Enrolment

We require two weeks written notice if you wish to terminate or change a full time booking to an hourly rate booking. Failure to do so will result in full fees being charged to your account.

Terms & Conditions of Enrolment

This fee schedule may be reviewed from time to time. At least two week’s notice of any changes will be given. The centre reserves the right to add, amend, delete or clarify conditions or policies by issuing newsletter, notices or posting notification on the centre notice boards.

Privacy Act

The information requested in this enrolment application form is needed by the centre to comply with statutory requirements. We are obliged by regulation to keep these records for at least 7 years. In the unlikely event that it is necessary to refer your account to a debt collection agency, information supplied by you will be made available to the debt collection agency.

Short Local Outings
I give permission for my child to go on short local regular outing and walks etc provided my child is in the supervision of Kumeu Childcare Qualified Teachers and appropriate ratios of 1:3 are maintained at all times. Refer to Kumeu Childcare Excursion Policy for appropriate staff: child ratios for all short outings
Parent/Guardian Signature:	Date:

Photo & Videos
I give permission for my child to be photographed/ Videoed for the purposes of
Facebook	Marketing	Planning, Assessment and Evaluation
Parent/Guardian Signature:		Date:

Declaration
By signing this form, you agree to the terms and conditions of this fee, Payment & Terms schedule. You also agree to abide by centre policies & procedures which are subjects to change from time to time. I declare that all the above information is true and correct to the best of my knowledge. Parent Declaration I declare that all the above information is true and correct to the best of my knowledge.
Parent/Guardian Signature:	Date:
Service Declaration On behalf of Kumeu Childcare I declare that this from has been checked and all relevant sections have been completed.
Service Provider Signature:	Date:

Change of Days/Times of Enrolment:

Effective Date of Change:

Days Enrolled:	Monday	Tuesday	Wednesday	Thursday	Friday	Total
Times Enrolled:
For 20 Hours ECE fill out boxes below
20 Hours ECE at this service
20 Hours ECE at another service
Parent/Guardian Signature:				Date:

Change of Days/Times of Enrolment:

Effective Date of Change:

Days Enrolled:	Monday	Tuesday	Wednesday	Thursday	Friday	Total
Times Enrolled:
For 20 Hours ECE fill out boxes below
20 Hours ECE at this service
20 Hours ECE at another service
Parent/Guardian Signature:				Date:

Change of Days/Times of Enrolment:

Effective Date of Change:

Days Enrolled:	Monday	Tuesday	Wednesday	Thursday	Friday	Total
Times Enrolled:
For 20 Hours ECE fill out boxes below
20 Hours ECE at this service
20 Hours ECE at another service
Parent/Guardian Signature:				Date:

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Referral
Website
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Walk In
Newspaper
Flyer
Other	(Please Specify)

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