Child Information Form - L'Chaim Chabad

Child Details

Child Information

Child Details

First Name*

Middle Name

Last Name*

Gender*MaleFemale

Date of Birth*

Place of Birth

CRN

Address*

Suburb*

State*

ZIP*

School*

Is your child of Aboriginal or Torres Strait Islanders descent?*YesNo

Is your child attending another Child Care Centre?*YesNo

Name

What is your CCB

Please allocate where CCB should be applied

Chabad Youth

Other Child Care Provider

Parent 1

First Name*

Middle Name

Last Name*

Gender*MaleFemale

Date of Birth*

Place of Birth

CRN

Address*Same address as child

Suburb*

State*

ZIP*

Home Phone*

Work Phone*

Mobile*

Email*

Preferred Method of Contact*Home PhoneWork PhoneMobileEmail

Occupation

Place of Work

Work Starts

Work Ends

Languages Spoken at Home

Concession/Health Care Card Holder?YesNo

Commonwealth Seniors Health Care Card

Ex-Carer Allowance (Child) Health Care Card

Foster Child Health Care Card

Health Care Card

Low Income Health Care Card

Pensioner Concession Card

Is the Natural mother of the child Jewish?*YesNo

Are there any conversions in the family? If yes please specify details of the conversions*YesNo

Family Status*Both Parents at HomeSole ParentShared CustodyOther

If you are separated or divorced, who has legal custody of the child?Parent 1Parent 2Other

Parent 1 Access arrangementsFullLimited

Parent 2 Access arrangementsFullLimited

Are there any court orders relating to he powers and responsibilities of the parents in relation to the child or access to the child?YesNo

Parent 2

First Name

Middle Name

Last Name

GenderMaleFemale

Date of Birth

Place of Birth

CRN

Address

Suburb

State

ZIP

Home Phone

Work Phone

Mobile

Include in email communication

Preferred Method of ContactHome PhoneWork PhoneMobileEmail

Occupation

Place of Work

Work Starts

Work Ends

Languages Spoken at Home

Concession/Health Care Card Holder?YesNo

Commonwealth Seniors Health Care Card

Ex-Carer Allowance (Child) Health Care Card

Foster Child Health Care Card

Health Care Card

Low Income Health Care Card

Pensioner Concession Card

Medical Information

Medicare Number*

Medical Centre Name*

Doctor's name*

Doctor's Phone*

Doctor's Address*

Dentist's name

Dentist's Phone

Dentist's Address

Maternal Child and Health Centre

Maternal Child and Health Nurse

Maternal Child and Health Address

Private Health Insurer*

Ambulance Subscription

Authorisation for your child to self-administer medication

Has your child been diagnosed at risk of Anaphylaxis?*YesNo

Any allergies: eg. food, medication, animals, insects etc?*YesNo

Any special dietary requirements?*YesNo

Any problems with hearing, sight or speech?*YesNo

Any health problems, operations, illnesses, diabilities?*YesNo

Does your child take any regular medications?*YesNo

Does your child have any physical disability or delay, including intellectual, sensory and physical impairment?*YesNo

Does either parent have a disability?*YesNo

ImmunisationsNot Immunised

	Birth	2 mo	4 mo	6 mo	12 mo	18 mo	4 yrs
Hepatitis B
Diphtheria
Tetanus
Pertussis
Polio
Hib
Pneumococcal
Rotavirus
Measles
Mumps
Rubella
Meningococcal C
Varicella

Emergency/Authorised Contact

Emergency/Authorised Contact
other than parent. Please include anyone who might collect your child from our centre.

Person 1:

Name*

Relationship to Child*

Address*

Suburb*

State*

ZIP*

Home Phone*

Work Phone

Mobile

This person has the authority to:

Collect/Deliver your child to/from the service

Give permission for excursions out of the service

Consent to medical treatment for your child

Permit transportation of your child by Ambulance

Request/Permit medication to be give to your child

If the parent/guardians cannot be contacted, this person should be notified of any accident, injury, trauma or illness involving your child

Person 2:

Name*

Relationship to Child*

Address*

Suburb*

State*

ZIP*

Home Phone*

Work Phone

Mobile

This person has the authority to:

Collect/Deliver your child to/from the service

Give permission for excursions out of the service

Consent to medical treatment for your child

Permit transportation of your child by Ambulance

Request/Permit medication to be give to your child

If the parent/guardians cannot be contacted, this person should be notified of any accident, injury, trauma or illness involving your child

Person 3:

Name*

Relationship to Child*

Address*

Suburb*

State*

ZIP*

Home Phone*

Work Phone

Mobile

This person has the authority to:

Collect/Deliver your child to/from the service

Give permission for excursions out of the service

Consent to medical treatment for your child

Permit transportation of your child by Ambulance

Request/Permit medication to be give to your child

If the parent/guardians cannot be contacted, this person should be notified of any accident, injury, trauma or illness involving your child

Authorisations

Are there any aspects of your child's cultural, ethnic and/or religious background that you would like us to be aware of?*YesNo

Are there any religious activities the staff should be aware of?*YesNo

I hereby authorise a Yeshivah/Beth Rivka OSHC staff and/or volunteer to obtain any medical care necessary for my child, including from a medical practitioner, hospital or ambulance service. I understand that transportation to receive medical care may include an ambulance and I agree to pay for any costs involved with seeking medical care for my child. I understand that in the case of an emergency of significant illness or injury attempts will be made to contact myself or an authorised nominee, as soon as practical*

I hereby authorise Yeshivah/Beth Rivka OSHC staff and/or volunteers to photograph my child and use the photographs for any Yeshiva Beth Rivka OSHC for the following purposes:

Yes, Educational Purposes

Yes, Promotional Materials

Yes, Social Media

I hereby acknowledge that I will/have read, understood and agree to the terms outlined in the Family Handbook (copies avilable on this website)*

I will provide Yeshiva Beth Rivka OSHC and/or volunteers with documentation regarding any medical conditions for my child and attached the relevant and up to date Medical Management Plans.*

I understand that if my child has a Medical Management Plan I will be required to complete a Risk Minimisation Form and a Communication Plan in consultation with Chabad Youth staff and/or volunteers.*

I permit my child to go home alone.

I allow my child to take part in water based activities.*YesNo

I give permission for my child to have a band aid administered.*YesNo

I give permission for my child to have sun screen applied.*YesNo

Signature

Sign on the line with your mouse or finger