Children'S Services Enrolment Form Part B: Family Form (Page 3 of 4) in pdf

Children'S Services Enrolment Form Part B: Family Form Page 3

Declaration

I _______________________________________ the authorised person of the child/ren referred to in

Print Full Name

Part A: Child Form, declare:

 That the information provided on this form is true and correct and that I undertake to immediately inform

the service in the event of any change to this information.

 I agree to follow the Fees policy as provided by the service and make all fee payments in accordance

with policy.

 Consent to Seek Emergency Assistance

Authorisation by parent/authorised person for the approved provider, nominated supervisor or educator to

seek:

o Medical treatment for the child from a registered medical practitioner, hospital or ambulance

service; and

o Transportation of the child by an ambulance

_________________________

___ / ___ / ____

Parent/guardian Signature

Date

___________________________

___ / ___ /____

Verified by staff member

Date

This form will be required to be updated and verified annually.

(Staff member to complete when enrolment form has been reviewed/updated throughout the year)

 _____ / _____ / _______

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Children'S Services Enrolment Form Part B: Family Form Page 3