ENROLMENT FORM Confidential Application Date_____________ CHILD First Name(s)___________________________ Surname _________________ Start Date _______________ Address ________________________________________________________ Birth Date _______________
Please supply copy of birth certificate Postal Address__________________________________ Post Code___________Female/Male _____________ PARENT/GUARDIAN/WHANAU PARENT/GUARDIAN/WHANAU
Name_________________________________________ Name ___________________________________ Address ______________________________________ Address __________________________________ _____________________________Post Code________ ___________________________Post Code_______ Home Phone________________ Mobile ____________
Home Phone _______________ Mobile ___________
Email _______________________________________ Email _____________________________________ Place of work _________________________________ Place of work _______________________________ Work Phone ________________ Fax ______________
Work Phone _______________ Fax _____________
EMERGENCY CONTACT Name________________________________________ Address ___________________________________ Relationship to Child ____________________________ Home Phone____________ Work Phone __________ MEDICAL INFORMATION Family Doctor_____________________________________________ Phone __________________________ Please record details of any special needs (e.g. physical, allergies etc. and any medications required). For long-term medication e.g. Ventolin, parents must give the Educator written permission to administer. Is your child enrolled at a Dental Clinic? YES / NO
IMMUNISATIONS Vaccine schedule for children born after Feb 2002
Member of New Zealand Home-based Early Childhood Education Assn.
ENROLLED HOURS – Please record start and finish time for each day in care Monday_____________________ Tuesday _________________ Wednesday _________________ Thursday ___________________ Friday ___________________ Saturday ____________ Sunday __________ Variable – Total weekly hours ____________________________ * I agree that if my child is enrolled with Variable Hours that he/she will attend for at least the minimum hours per week as stated above. WINZ SUB YES / NO Hours _________ App. Date ____________ (Copy Attached) WINZ Contact ____________ Total to pay _____________ Less WINZ _____________ Less KWS ______________ TO PAY ____________ If your child is aged 3 or 4 years old will your fees or part fees be paid by the Government with 20 hours Free ECE YES NO Ethnic origin of child (Maori, European, Pacific Island etc) _____________________ First language of child ___________________________ If child identifies as Maori, please, enter the name(s) of her/his iwi.
You may enter more than one iwi. If you do not know the iwi, please enter ‘Don’t know’ Rohe (iwi home area):
Only those persons who have right of access and are named below will be allowed to collect your children from the Educators home. (Unless special arrangements are made). Name ___________________________________________________ Phone _____________________ Mobile _____________________ Name ___________________________________________________ Phone ______________________ Mobile ____________________ Kindergarten _____________________________________________ Times enrolled _________________________________________ I HAVE READ AND UNDERSTAND THE FOLLOWING: I understand A Kidz World Management reserves the right to seek professional guidelines in cases of suspected child abuse. I understand that the Ministry of Education regulations forbids the use of corporal punishment. I will bring my child dressed appropriately for the weather and play AND provide sunhats, jackets, warm hats and spare clothes. I give permission for this child to travel in the Educator’s vehicle and to be taken for walks and excursions by the Educator. I accept that in the case of my Educator having to obtain medical treatment in an emergency it is my responsibility for expenses incurred. I give permission for the Educator to apply basic First Aid and sunscreen products to this child, and to change his/her wet or soiled clothing when necessary. I understand that when children are in care, parents & A Kidz World staff have the right of entry into the home. I give permission for this child to be taken to an alternative emergency location e.g. Civil Defence Centre in the event of an emergency. I understand it is my responsibility to sign my child’s weekly time sheet, and check the recorded daily start and finish times. I agree to pay the enrolled hours or the actual attended hours, whichever is the greater. I understand that fee payments are due each Friday the end of the weekly care period. I understand that care will automatically stop on the 1st Monday following two weeks non payment of fees. I understand care will only resume once payment has been made in full. I agree to pay for absences where I have not given seven days notice. I will pay for time and $1.00 per km if my Educator has to deliver or collect from Kindergarten. I have not enrolled my child at any other Service (e.g. Day Care, Kindergarten) for the same hours of attendance. I give permission for photographs to be taken of my child. I would / would not like my child’s photo to appear in marketing material e.g. A Kidz World website, pamphlets and news letters. SIGNATURES: Parents / Whanau ________________________________________________________________ DATE __________________________ Please note: A Kidz World must be advised immediately of any changes to enrolment arrangements. EDUCATOR: Name ________________________________________________ Emergency Educator ________________________________________ Address ______________________________________________ Address _________________________________________________ Phone ________________________________________________ Phone ___________________________________________________
Member of New Zealand Home-based Early Childhood Education Assn.
AS A PARENT, I WILL –
- Provide a copy of your child’s birth certificate or passport with enrolment form
Be provided with a choice of Educator wherever possible.
Give the Educarer all the necessary details to help in providing care and education of my child e.g. Routines for sleeping, any health problems etc.
Notify the Educator immediately if I cannot pick up my child as arranged. Extra time will be charged for.
Understand that if my child becomes ill I will be notified and may be required to collect my child immediately. Will not take a sick child to the Educator.
Be notified as soon as possible in case of accident or illness. I wil also be responsible for any medical expenses in the case of urgent treatment for my child.
Be expected to spend time settling my child into care.
Be responsible for supplying my children’s meals and drinks.
For babies, supply enough nappies, bottles and changes of clothes. For older children, enough changes of clothes must be provided.
Sign and read my child’s Individual Profile Sheet.
Give permission for outings and travel in the Educator’s car.
Give written advice on who is permitted to pick my child up.
Notify the Educator immediately if my child will be absent.
Notify changes of address immediately as they are important in emergencies.
Give a weeks notice of care finishing in writing to both the Educator and A Kidz World.
Be courteous to the Educator by notifying any changes to arranged hours or circumstances.
Ask A Kidz World for alternative or emergency care when their usual Educator is unavailable.
Be welcome to attend training, playgroups or other meeting arranged by A Kidz World.
Be welcome to discuss my child’s progress and any concerns with the Educator or A Kidz World Management.
Be welcome to discuss with A Kidz World Management any conflicts or concerns about the child/ren or care situation you may have.
Pay my fees weekly at the end of the care period. When possible attach a cheque to the Educator’s timesheet, or will set up an automatic payment or internet banking.
Agree that if a debt remains unpaid after two reminder notices have been sent, the debt will be sent to a Debt Collection Agency for recovery and you will be liable for collection and legal costs as well as the original amount.
SIGNATURES:
Parents / Whanau _____________________________________________________________ Date ______________________________ Educator ___________________________________________________________________ Date ______________________________ Care Arranger _______________________________________________________________ Date ______________________________
Member of New Zealand Home-based Early Childhood Education Assn.
General Information about your Birth Birth facility: Hospital Alternative Birthing Center Home I am choosing to have a Natural Birth Medically-Assisted Birth Planned Cesarean Birth (Gentle Cesarean page 7) Names of those attending your labor and birth: Partner Doula Child Other support I have prepared for my birth by taking/learning
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ENROLMENT FORM Confidential