Enrolment Record – Jenny's Early Learning Centre

Your Child's Information

This form must be completed by a parent or guardian who has lawful authority in relation to the child. Enrolment may be delayed if forms are incomplete (Children's Services Law, Education and Care Service National Law, Regulations 160–162).

Be prepared to provide Photo ID when collecting your child. Please ensure all fields are filled correctly.

Child's First Name *

Child's Middle Name

Child's Last Name *

Preferred Start Date

How Did You Hear About Us? *

Requested Days of Attendance *

Video Surveillance: Jenny's ELC are under 24-hour video surveillance. By enrolling you agree to our Video Surveillance Policy. No cameras in toilets or areas that encroach on privacy.

Your Child's Details

Full legal name: — (from the previous step)

Usually Called

Date of Birth – Child *

Child's Gender at Birth *

Child's Gender Identity *

Child's Pronouns

Home Address – Child *

CRN – Child *

Medicare Number – Child *

Medicare IRN – Child *

Medicare Expiry – Child

Ambulance Cover Number

Private Health Fund – Child (if applicable)

Private Health Number – Child (if applicable)

Language(s) Spoken At Home – Child *

Child's Culture / Cultural celebrations

Parent/Guardian 1

Parental responsibility is defined in the Family Law Act 1975. All parents have powers and responsibilities in relation to their children unless changed by court order.

Parent/Guardian 1 *

Parent 1 Guardian 1

First Name *

Last Name *

Preferred Name

Date of Birth *

Gender Identity *

Preferred Pronouns

Address *

Email Address *

Telephone (Mobile) *

Telephone (Home)

Telephone (Work)

CRN – Parent/Guardian 1 *

Is the child linked to Parent/Guardian 1 CRN?

Yes No

Language(s) Spoken At Home *

Parent Cultural Background

Parent/Guardian 2

If not applicable, click Next.

Parent/Guardian 2

Parent 2 Guardian 2

First Name

Last Name

Preferred Name

Date of Birth

Gender Identity

Preferred Pronouns

Address

Email Address

Telephone (Mobile)

Telephone (Home)

Telephone (Work)

CRN – Parent/Guardian 2

Is the child linked to Parent/Guardian 2 CRN?

Yes No

Language(s) Spoken At Home

Parent Cultural Background

Authorised Persons (1)

We must keep contact details of persons authorised to: consent to ambulance transport; authorise educator to take child outside premises; consent to medical treatment/medication; be notified in emergency; collect the child (Authorised Nominee).

Name – Authorised Person 1 *

Address *

Telephone (Mobile) *

Telephone (Home)

Telephone (Work)

Email *

Relationship to child *

Parent/Guardian 1 – Type your name to confirm *

Add another authorised person?

Yes No

Authorised Person 2

Name – Authorised Person 2 *

Address *

Telephone (Mobile) *

Email *

Relationship to child *

Parent/Guardian 1 – Type your name to confirm

Court Orders, Parenting Orders or Parenting Plans

Parenting Order: s64B(1) Family Law Act. Parenting Plan: s63C(1). If yes, bring original court orders for staff to see and a copy to attach.

Are there any Court Orders, Parenting Orders or Parenting Plans relating to the child or access? *

Yes No

Details of Court Orders relating to residence or contact? *

Yes No

Do orders change powers to consent to medical treatment? *

Yes No

Do orders change powers to request/permit medication? *

Yes No

Do orders change powers to collect child from JELC? *

Yes No

Do orders give powers to someone else? *

Yes No

Child's Registered Practitioner / Medical Service

Name of child's Registered Practitioner or Medical Service *

Telephone *

Address *

Maternal & Child Health (MCH) Centre

Does your child have a child health record? *

Yes No

Child's Medical Information

Anaphylaxis

Has your child been diagnosed at risk of anaphylaxis? *

Yes No

Does your child have an auto-injection device (e.g. EpiPen)? *

Yes No

Anaphylaxis Medical Management Plan provided to JELC?

Yes No Not Applicable

Allergic Reaction

Does your child have any allergies? *

Yes No

Does your child require allergy medication?

Yes No

Allergy Action Plan provided to JELC?

Yes No Not Applicable

Asthma

Has your child been diagnosed at risk of Asthma? *

Yes No

Does your child require Asthma medication?

Yes No

Asthma Management Plan provided to JELC?

Yes No Not Applicable

Epilepsy

Has your child been diagnosed at risk of Epilepsy? *

Yes No

Seizure Care Plan provided to JELC?

Yes No Not Applicable

Other Medical Conditions

Any other medical conditions/health care needs? (e.g. diabetes) *

Yes No

Details of management procedure

Previously suffered medical conditions staff should be aware of? *

Yes No

Details

Paracetamol

Is your child allergic to Paracetamol? *

Yes No

Permission for staff to administer Paracetamol *

Yes, I give permission No, I do not give permission

Name *

Date *

Band Aids and Sunscreen

Sensitivity to sunscreen? *

Yes No

Permission – Sunscreen *

I give permission for JELC staff to apply centre sunscreen I wish to provide sunscreen for my child

Sensitivity to band-aids? *

Yes No

Permission – Band-aids *

I give permission for JELC staff to apply centre band-aids I wish to provide band-aids for my child

Name (confirm sunscreen/band-aid)

Date

Immunisation Information

Victoria's No Jab, No Play: you must provide an Immunisation History Statement from the Australian Immunisation Register (AIR) showing fully immunised, approved catch-up schedule, or medical exemption.

Has your child been immunised? *

Yes No

Upload Immunisation History Statement (AIR) *

PDF or image. From myGov or Medicare.

Upload other documents (e.g. medical plans, court orders)

Optional: Anaphylaxis/Asthma/Allergy plans, court order copies.

Other Permissions

Incursions

I give permission for my child to attend incursions (visits to JELC) *

Yes No

Name *

Date *

Excursions

I give permission for my child to attend excursions (external to JELC) *

Yes No

Name *

Date *

Getting to Know You and Your Child

Is your child of Aboriginal and/or Torres Strait Islander origin? *

Does your child have a developmental delay or disability? *

Yes No

Details

Additional needs (language, speech, physical, etc.)? *

Yes No

Details

Dietary requirements, restrictions or preferences? *

Yes No

Instructions or restrictions

Cultural/religious requirements for program planning? *

Yes No

Details

Traits and characteristics (optional)

Other children in your family (optional)

Getting to Know You (Optional)

Parent/Guardian 1 – Occupation

Work Place

Parent/Guardian 1 – Work Address

Does your child live with Parent/Guardian 1?

Yes No

Skills or interests to share with children at JELC?

Parent/Guardian 2 – Occupation

Work Place

Parent/Guardian 2 – Work Address

Does your child live with Parent/Guardian 2?

Yes No

Skills or interests to share?

Acknowledgements & Agreements

Emergency: JELC is authorised to seek medical treatment/hospital/ambulance as needed. Fees: minimum 2 weeks in advance; fees for absent/public/sick days; 4 weeks notice for withdrawal or change of days; first/last 6 weeks rules apply.

Name – Emergency Acknowledgement *

Date *

Name – Fee, Withdrawal and Date Change Acknowledgement *

Date *

Name – Policy Agreement *

Date *

Payment Method *

Direct Debit (Bank Account) Credit Card

Privacy Consent & Signatures

By signing you consent to Jenny's ELC collecting, using, storing and disclosing personal information for education and care, administration, emergency care, compliance and communication. We may share with Department of Education, regulators, medical professionals. See our Privacy Policy.

I have read and consent to the Privacy statement above *

I agree to receive other communications from Jenny's ELC

Parent/Guardian 1 signature *

Printed name *

Date *

Parent/Guardian 2 signature (optional)

Printed name

Date

Your Child's Information

Your Child's Details

Parent/Guardian 1

Parent/Guardian 2

Authorised Persons (1)

Authorised Person 2

Court Orders, Parenting Orders or Parenting Plans

Child's Registered Practitioner / Medical Service

Child's Medical Information

Anaphylaxis

Allergic Reaction

Asthma

Epilepsy

Other Medical Conditions

Paracetamol

Band Aids and Sunscreen

Immunisation Information

Other Permissions

Incursions

Excursions

Multi-Media (photos/video)

Getting to Know You and Your Child

Getting to Know You (Optional)

Acknowledgements & Agreements

Privacy Consent & Signatures