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| Child's Surname: | Date of Birth: | |||
| Child's Given Name: | Age: | Sex: | ||
| Address: |
Phone No: Mobile No: |
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| No. of Children in family: |
Child's position in family: |
Languages spoken: | ||
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MOTHER
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FATHER
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| Name: | Name: | |
| Occupation: | Occupation: | |
| Employer's Name: | Employer's Name: | |
| Business address: | Business address: | |
| Phone No: | Phone No: | |
| Country of Origin: | Country of Origin: | |
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| Collector's name: |
Phone No:
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| Address: | |
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Any court orders, re: custody/access? Yes: If yes please provide a copy of the Court Order |
No: |
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| Contact's name: | Phone No: |
| Address: | |
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| Family Doctor's Name: | Phone No. |
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Address: |
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Immunisation Yes: If yes please provide a copy of the certificate |
No: |
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Is your child on regular medication, or have any allergies or other relevant medical history we should know about?
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| Days of Care: |
Mon
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Tues
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Wed
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Thur
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Fri
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Hours in Care:
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Date of Enrolment:
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Enrolment Fee
Paid:
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Cultural religious, related to disabilities or special needs etc.
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Although every care will be taken of your child while at the the centre, the staff can in no way be held responsible for any accident which may occur. In the event of an accident or illness requiring emergency treatment, every effort will be made to contact the parents before such treatment is sought. However, should this prove impossible, it will be necessary for authority to be given for the treatment to be undertaken. On signing below, I authorise the staff of the Centre to seek emergency treatment for my child should this be considered necessary. Furthermore, I have read and agreed to abide by conditions of use of the Centre and to accept such responsibility as enrolement at the Centre imposes. |
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| Signature of parent or guardian: | Date: |
| Signature of witness: | |