Enrol

1. 1. Given names: *
2. Surname / family name:
3. Address:
4. Phone (Home):
5. Phone (Work):
6. Phone (Mobile):
7. Email: *
8. Relationship to child: *

1. 2. Given names: *
2. Surname / family name:
3. Address:
4. Phone (Home):
5. Phone (Work):
6. Phone (Mobile):
7. Email: *
8. Relationship to child: *

Please provide your email id as the invoices and other information is sent to you by email.

1. Given names: *
2. Surname / family name:
3. Address:
4. Phone (Home):
5. Phone (Work):
6. Phone (Mobile):
7. Email: *
8. Relationship to child: *

1. Given names: *
2. Surname / family name:
3. Address:
4. Phone (Home):
5. Phone (Work):
6. Phone (Mobile):
7. Email: *
8. Relationship to child: *

1. Are there any custodial arrangements concerning your child? *
2. If YES, please give details of any custodial arrangements or court orders (a copy of any court order is required) *

3. Person(s) who cannot pick up your child:

4. Name:

5. Name:

6. Name:

7. Name:

1. 1. Given names: *
2. Surname / family name:
3. Address:
4. Phone (Home):
5. Phone (Work):
6. Phone (Mobile):
7. Email: *

1. 2. Given names: *
2. Surname / family name:
3. Address:
4. Phone (Home):
5. Phone (Work):
6. Phone (Mobile):
7. Email: *

1. 3. Given names: *
2. Surname / family name:
3. Address:
4. Phone (Home):
5. Phone (Work):
6. Phone (Mobile):
7. Email: *

1. 4. Given names: *
2. Surname / family name:
3. Address:
4. Phone (Home):
5. Phone (Work):
6. Phone: *
7. Email: *

1. Name:
2. Phone:
3. Name of medical centre: *

Illness/allergies:

1. Is your child up-to-date with immunisations? * YesNo
2. Is there any history of medical, behavioural, birth or any other difficulty * YesNo
3. For staff: Immunisation records sighted, and details recorded: * YesNo

1. Category (i) Medicines

3. Do you approve category (i) medicines to be used on your child? * YesNo
4. Parent/Guardian Signature: *
5. Date:

1. Category (ii) Medicines

2. 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.

3. Parent/Guardian Signature: *
4. Date: *

1. Category (iii) Medicines

2. 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.

3. For staff: Individual health plan sighted, and a copy taken: YesNo
4. Name of medicine: *
5. Method and dose of medicine: *

6. Specific symptoms and time for medicine

7. Parent/Guardian Signature: *
8. Date:

1. Date of Enrolment: *
2. Date of Entry: *
3. Date of Exit: *

4. 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.

5. Days Enrolled:

6. Monday *
7. Tuesday *
8. Wednesday *
9. Thursday *
10. Friday *
11. Total hours: *

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

1. 20 Hours ECE at this service

2. Monday *
3. Tuesday *
4. Wednesday *
5. Thursday *
6. Friday *
7. Total hours: *

1. 20 Hours ECE at another service

2. Monday *
3. Tuesday *
4. Wednesday *
5. Thursday *
6. Friday *
7. Total hours: *

1. Parent/Guardian Signature: *
2. Date: *

1. 1. Is your child receiving 20 Hours ECE for up to six hours per day, 20 hours per week at this service? YesNo
2. 2. Is your child receiving 20 Hours ECE at any other services? YesNo

3. If yes to either or both of the above, please sign to confirm that:

   (i) Your child does not receive more than 20 hours ECE per week across all services.

   (ii) 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.

   (iii) 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.

4. 1. Parent/Guardian Signature: *
   2. Date *

1. 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].

   1. Parent/Guardian Signature: *
   2. Date *

1. If you request Optional Charges, this agreement must be included as part of your service’s Enrolment Agreement Form.

   For further information on Optional Charges please refer to Chapter 4 of the Early Childhood Education Funding Handbook.

2. 1. The optional charge is for: (give details of specific activities or items, and their costs)

4. 2. I understand that if I agree to pay for the optional charge, Indigo Educare Limited may enforce payment.

5. 3. The agreement to pay the optional charge will last for: *

6. 4. The rules about making changes to the agreement are: (you must give the parent reasonable opportunity in which to change their mind):

8. 5. I understand that that optional charge is not compulsory and if I choose not to pay there will be no penalty.

9. 6. I agree/do not agree (select one) to pay the optional charge for the activities/items specified in this enrolment agreement form.

10. Parent/Guardian Signature: *
11. Date:

1. (i) Excursions: Permission for the child to take part in regular excursions (under the conditions stated in the service’s excursions policy).

   (ii) Photo/video: permission for the child to be photographed for the purposes of assessment, planning and evaluation (explain clearly how the photos/videos can/can’t be used)

1. (i) Policy Statement: Li’l Champs has several policies that set out the procedures 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.

   (ii) Child’s strengths, interests and preferences: Please tell us about your child’s strengths, interests and preferences.

1. I declare that all the above information is true and correct to the best of my knowledge.

2. Parent/Guardian Signature: *
3. Date: *

1. On behalf of Li’l Champ Learning centre, I declare that this form has been checked and all relevant sections have been completed.

2. Service Provider Signature: *
3. Date: *

1. Pass Port
2. Address proof
3. Immunisation record
4. Any medical Record
5. Driving Licence