Appendix 2 - References and Resources
Waimate Kindergarten Association ENROLMENT FORM CONFIDENTIAL
Kindergarten:
Date of Enrolment: ____ /____ / ____ / Date of Entry: ____ /____ / ____ / Date of Exit: ____ /____ / ____
Child:
Child’s official surname or family name:
Child’s official given name:
Child’s official other names / middles 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
New Zealand passport
Other ______/ Foreign birth certificate
Foreign passport
Staff initials: ______
Child’s date of birth: d d / m m / y y y y / Male / Female
Child’s ethnic origin/s:
______
______
______/ Iwi your child belongs to::
______
______
______/ Languages spoken at home:
______
______
______
Child’s primary residential address:
Post Code:
School child likely to attend:
Privacy:
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: www.minedu.govt.nz/parents
* Information about acceptable identity verification documents is available online at
www.lead.ece.govt.nz and www.minedu.govt.nz/parents.
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:: / Phone (Home):
Surname / family name: / Phone (Work):
Address: / Phone (Mobile):
Email:
Relationship to Child:
Post Code: / Occupation:
2. Given names:: / Phone (Home):
Surname / family name: / Phone (Work):
Address: / Phone (Mobile):
Email:
Relationship to Child:
Post Code: / Occupation:
3. Given names:: / Phone (Home):
Surname / family name: / Phone (Work):
Address: / Phone (Mobile):
Email:
Relationship to Child:
Post Code: / Occupation:
4. Given names:: / Phone (Home):
Surname / family name: / Phone (Work):
Address: / Phone (Mobile):
Email:
Relationship to Child:
Post Code: / Occupation:
Signed by Parent/Guardian ______
Date: ______
How did you find out about our Kindergarten? / Why did you choose our Kindergarten?
£ Friends/Family £ Yellow Pages
£ Newspaper £ Radio
£ Always knew you were there £ Other Advertising
£ Noticed the Kindergarten sign / £ Close to home £ Close to schools
£ Close to work £ Quality of service
£ Heard good things about it £ Low cost
£ Other children in family came here
Page one and two to be completed before your child’s name is added to our Waiting List, remaining pages to be completed before Start Date.
Child’s Official Name:
Given Names: / Phone (Home):
Surname / family name: / Phone (Work):
Address: / Phone (Mobile):
Email:
Post Code:
Relationship to Child:
Given Names: / Phone (Home):
Surname / family name: / Phone (Work):
Address: / Phone (Mobile):
Email:
Post Code:
Relationship to Child:
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: / Name:
Name: / Name:
Additional Person/s who can pick up your child:
1. Given Names: / 2. Given Names:
Surname / family name: / Surname:
Phone (Home): / Phone (Home):
Phone (Work): / Phone (Work):
Phone (Mobile): / Phone (Mobile):
Relationship to Child: / Relationship to Child:
3. Given Names: / 4. Given Names:
Surname / family name: / Surname / family name:
Phone (Home): / Phone (Home):
Phone (Work): / Phone (Work):
Phone (Mobile): / Phone (Mobile):
Relationship to Child: / Relationship to Child:
Child’s Doctor:
Name: / Phone:
Address:
Name of Medical Centre:
Health
Illness/allergies:
Is your child up-to-date with immunisations? / Tick One / Yes / No
(Please provide verifications of all immunisations)
Immunisations record sighted and details recorded: / Tick One / Yes / No
Cultural Consideration:
Please tell us about any cultural considerations around food and or food preparation.
Medicine
Category (i) Medicines:
A category (i) medicine is a non-prescription preparation that is not ingested, used for the ‘first aid’ treatment of minor injuries and provided by the kindergarten and is kept in the first aid cabinet.
Following are the name/s of specific category (i) medicines that are provided by the kindergarten.
Please tick to approve the category (i) medicines to be used on your child.
§ Sodium Chloride Irrigation Solution / c Yes c No
§ Sunscreen / c Yes c No
· Aloe Vera Gel / c Yes c No
· Antiseptic skin cleansing wipes / c Yes c No
· Arnica Cream / c Yes c No
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
Individual health plan completed and signed: Tick One / Yes / No
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: ____ /____ / ____
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 number
of hours:
For 20 Hours ECE fill out boxes below with hours attested e.g. 6 hours
20 Hours ECE at this service / Total number
of hours:
20 Hours ECE at another service / Total number
of hours:
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?
Yes / No
2. Is your child receiving 20 Hours ECE at any other services? Tick One / Yes / No
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.
§ You 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 a Waimate Kindergarten Association Kindergarten
Parent/Guardian Signature: ______/ Date: ____ /____ / ____
Fee Agreement
I have read a copy of the Waimate Kindergarten Association Free Procedure and agree to pay any fees arising from my child’s enrolment at Kindergarten. I elect to pay fees on the following basis.
§ Monthly
Method of Payment (Please circle one)
§ Automatic Payment / § Internet Banking / § Cheque or Cash
(BNZ 02-0892-0010000-00 Reference: Child’s Name)
Parent/Guardian Signature: ______/ Date: ____ /____ / ____
Optional Charges:
1. The optional charge are for:
a. A one off optional charge to support the cost of the portfolio books.
2. I understand that if I agree to pay for the optional charge, Waimate Kindergarten Association may enforce payment.
3. The agreement to pay the optional charge will last for the duration of the enrolment.
4. The rules about making changes to the agreement are:
§ contact must be made with the Head Teacher and a new agreement will be completed.
5. I understand that that optional charge is not compulsory and if I choose not to pay there will be no penalty.
6. I agree/do not agree (select one) to pay the optional charge for the activities/items specifiedin this enrolment agreement form
Parent/Guardian Signature: ______/ Date: ____ /____ / ____
Term Breaks:
This enrolment agreement is exclusive of school term breaks.
Parent/Guardian – Statement of Understanding:
I understand that if my child is leaving kindergarten (other than going to school), I will endeavour to give two (2) weeks notice and that if I don’t, I may still be asked to pay fees. / c Yes c No
I give permission for my child’s details to be given to:
· the school for roll predictions; / c Yes c No
· any visiting health professionals; / c Yes c No
· any visiting education specialists; / c Yes c No
· the kindergarten committee for fundraising purposes; / c Yes c No
· the kindergarten newsletters; and / c Yes c No
· other teachers if transferring. / c Yes c No
I understand that the Waimate Kindergarten Association has a number of policies and procedures that set out how the care and education of the children who attend is provided. We strongly urge you to read these. The signing of this enrolment agreement form indicates that you will abide by the procedures of this service, and understand who you can have input to procedure/policy review. / c Yes c No
I give permission for this child to be taken on walks and outings (these are defined as short trips within the excursion and travel arrangements procedure) to places in the immediate local community within walking distance of the kindergarten as detailed below: Ratio of 1:4
· short trips with the teaching staff in the area around the kindergarten; and
· on visits with the teaching staff to local school’s on transition to school excursions. Information and discussion will be held with you prior to the school excursions. / c Yes c No
I have read and understand the Excursion and Travel Arrangements Procedure. (Ratio 1:4) / c Yes c No
I give permission for this child to be photographed or videoed at the kindergarten for learning related purposes.
This will include the processes of assessment, planning and evaluation. I understand that other families will have access to these. / c Yes c No
I give permission for this child to be photographed or videoed at the kindergarten for publicity purposes, including the Waimate Kindergarten Association website and Facebook Page. / c Yes c No
I give permission for samples of this child’s work to be used in displays at the kindergarten and/or in the community. / c Yes c No
I give permission for the teachers to change her/his soiled or wet clothing when necessary. / c Yes c No
I give permission for details of this child’s medical information being publicly displayed in the Kindergarten for teachers, relieving teachers and parent help information in order to keep this child safe. / c Yes c No
I accept responsibility for costs of any medical treatment required by this child in an emergency situation. / c Yes c No
I give permission for my child to be observed by students and other training professionals. / c Yes c No
I give permission for this child to be involved in the use of ICT including use of suitable internet sites for educational purposes with teacher supervision. I understand observations of my child will be made by the staff and teachers. / c Yes c No
I understand that if I use my own camera to take photos of my own child/ren at kindergarten or on excursions and other children are in the photo(s) I will not use the photo(s) on Facebook or similar sites. / c Yes c No
Waimate Kindergarten Association has a number of policies and procedures 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 and procedure of this kindergarten, and understand how you can have input to policy and procedure review.
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 the Waimate Kindergarten Association I declare that this form has been checked and all relevant sections have been completed.
Service Provider Signature: ______/ Date: ____ /____ / ____
CHANGE OF ENROLMENT DETAILS FORM CONFIDENTIAL
Child’s Official Name:
Change of Enrolment Details:
Date Changes Effective From:
Parent/Guardian Signature: ______/ Date: ____ /____ / ____
Change of Enrolment Details:
Date Changes Effective From:
Parent/Guardian Signature: ______/ Date: ____ /____ / ____
Change of Enrolment Details:
Date Changes Effective From:
Parent/Guardian Signature: ______/ Date: ____ /____ / ____
Change of Enrolment Details:
Other Changes:
Date Changes Effective From:
Parent/Guardian Signature: ______/ Date: ____ /____ / ____
Note: Once change of enrolment details form has been completed please file on the FRONT of the enrolment form.