Church Street Educare 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:

1. Given names:

2. Given names:

Any changes to this form must be signed and dated by the parent/guardian.

Version: August 2015

Page 1 of 7

Surname / family name:

Address:

Post Code:

Phone (Home):

Phone (Work):

Phone (Mobile):

Email:

Relationship to child:

3. Given names:

4. Given names:

Surname / family name:

Address:

Post Code:

Phone (Home):

Phone (Work):

Phone (Mobile):

Email:

Relationship to child:

Additional person/s who can pick up your child:

Given names:

Surname / family name:

Address:

Post Code:

Phone (Home):

Phone (Work):

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:

Additional Emergency Contacts (also able to pick up child):

1. Given names:

2. Given names:

Any changes to this form must be signed and dated by the parent/guardian.

Version: August 2015

Page 2 of 7

Surname / family name:

Address:

Post Code:

Phone (Home):

Phone (Work):

Phone (Mobile):

Email:

3. Given names:

4. Given names:

Surname / family name:

Address:

Post Code:

Phone (Home):

Phone (Work):

Phone (Mobile):

Email:

Child’s doctor:

Name:

Phone:

Name of medical centre:

Health

Illness/allergies:

Is your child up-to-date with immunisations?

Tick One Yes

(Please provide verification of all immunisations)

For staff: Immunisation records sighted and details recorded:

Tick One Yes

Medicine

Category (i) Medicines

Any changes to this form must be signed and dated by the parent/guardian.

Version: August 2015

Page 3 of 7

A category (i) medicine is a non-prescription preparation (such as arnica cream, 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 Yes

Name/s of specific category (i) medicines that can be used on my child, provided by service:

Arnica

Antiseptic liquid

Rawleighs Medicated ointment

(active ingredients are Menthol

and Oil of Eucalyptus)

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: Yes

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:

Any changes to this form must be signed and dated by the parent/guardian.

Version: August 2015

Page 4 of 7

Enrolment Details:

Date of Enrolment: Date of Entry:

Date of Exit:

Please Note: 20 Hours ECE is for up to six hours per day, up to 20 hours per week and there must be no

compulsory fees when a child is receiving 20 Hours ECE funding.

Days Enrolled:

Monday

Tuesday

Wednesday

Thursday

Friday

Times Enrolled:

Total hours:

For 20 Hours ECE fill out boxes below with the hours attested e.g. 6 hours

20 Hours ECE at this

Total hours:

service

20 Hours ECE at

Total hours:

another service

Parent/Guardian Signature:

Date:

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 Yes

2. Is your child receiving 20 Hours ECE at any other services?

Tick One Yes

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:

Any changes to this form must be signed and dated by the parent/guardian.

Version: August 2015

Page 5 of 7

Additional Fees

The daily charge applying at the time of this enrolment is required to allow Church Street Educare (a teacher-led

early childhood service) to provide aspects of education and care that are over and above regulatory standards.

These include… licensee qualifications above minimum requirements; having more than 80% registered

teachers, child enrolments maintained at below license allowance.

Parent/Guardian Signature:

Date:

I give permission for ...

• my child’s head to be checked for head lice by teachers. I am aware that in the case of my child having head

lice, s/he may be asked to stay home until treated.

Yes No

• my child to be taken to the Doctor or to hospital in an ambulance if necessary in the unlikely event of a

medical emergency. Parents or a contact person will be notified immediately.

Yes No

• my child to take part in planned excursions (under the conditions stated in the excursions policy).

Yes No

• my child to take part in unplanned excursions i.e walk to the park or school (under the conditions stated in

the excursions policy).

Yes No

• my child to be photographed/videoed for the purposes of assessment, planning and evaluation.

Yes No

• assessment, planning and evaluation information concerning my child to be shared publicly ie. newsletters,

displays, portfolios, website.

Yes No

Other information possible to include on this Enrolment Agreement Form

Policy Statement: Church Street Educare has a number of policies that set out the procedures that are in

place for the care and education of the children who attend. We strongly urge you to read these. The signing

of this enrolment agreement form indicates that you will abide by the policies of this service, and understand

how you can have input to policy review.

Schoot Visits: If known at the time of enrolment, please record the name of the school your child is most

likely to attend.

Parent/Guardian Signature:

Date:

Any changes to this form must be signed and dated by the parent/guardian.

Version: August 2015

Page 6 of 7

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 Church Street Educare, I declare that this form 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

Times Enrolled:

Total

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

Times Enrolled:

Total

For 20 Hours ECE fill out boxes below

20 Hours ECE at this

service

20 Hours ECE at another

service

Parent/Guardian Signature: Date:

Any changes to this form must be signed and dated by the parent/guardian.

Version: August 2015

Page 7 of 7