Which Holiday Programme Date and Location Do You Wish Your Child to Attend?
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Additional Child Application Form
Note: Has your child previously attended a KidzaCool programme? If Yes, use the KidzaCool Child Details Update Form to update your current details. If No, please complete this form. Which holiday programme date and location do you wish your child to attend?
Preferred KidzaCool Adventure date and location: ______
Additional Child’s Details Name of child Male Female Date of birth
/ / Child has lived with current caregiver(s) since Ethnicity: NZ Maori NZ European Date ……………/………………/…………… Indian Cook Is How many children live with caregiver Tongan Niuean Fijian Tokelauan Do you have legal custody / guardianship Yes / No Samoan Other Pacific Is If no, name of person who has legal custody/guardianship for child Other Other European Not known South East Are you receiving a Home for Life support package for this child? Asian Other Other Asian Yes No Iwi
Te Hapu
General Information
Is there any other information that you would like us to know about your child?
Children are placed in groups - is there a friend or sibling attending that your child would like to be grouped or not grouped with?
2 Stand Children’s Services KidzaCool Additional Child Application Dec 2015
Additional Child’s Name______Behaviour and Health Checklist The following behaviours are indicators for us of the level of support your child will need. Please tick in the boxes all of those behaviours that apply to your child. Does your child often: No Yes No per Has your child: No Yes No of week times Lose his/her temper? Run away from home?
Argue with adults? Run away from school?
Defy or refuse adult Broken into someone’s requests or rules? house or car? Deliberately do things to Deliberately destroyed annoy people? other’s property? Blame others for own Deliberately destroyed their mistakes? own property? Get touchy or easily Been physically cruel to annoyed by others? animals? Seem angry and resentful? Been physically cruel to people? Act spitefully or vindictively? Used a weapon in more than one fight? Swear or use obscene Deliberately set fires? language? Lie? Stolen?
Skip school? Displayed sexualized behaviour? Initiate physical fights?
Office use only: Risk Assessment: High Medium High Medium Medium Low Low Health Information Is the child diagnosed as having any of the following conditions? Physical: Mental Developmental Enuresis ADD / ADHD Learning disability Encopresis Oppositional Defiance Disorder Intellectual disability Asthma Conduct disorder Sensory disability Epilepsy Anxiety disorder Aspergers Hearing problems Eating disorder Autism Vision problems Mood disorder Other Skin problems Phobic disorder Pls state ______ Diabetes Other Obesity Pls state______ Under weight Child cancer Other Pls state ______
3 Stand Children’s Services KidzaCool Additional Child Application Dec 2015
Additional Child’s Name ______
Any recent or current ill health?
Any special health needs we should be aware of?
Does the child suffer from any allergies e.g. food, bites, stings or medications?
Cause ______
Effect______
Is the child currently taking any medication? YES NO
Medication What for Dosage How Often
______
Has the child had contact recently (within the last three months) with any infectious diseases e.g. Mumps, Measles, Chicken Pox? YES NO
If YES please specify what disease: ______When ______
Please indicate which of the following immunisations the child has received (please circle)
Diptheria Tetanus Whooping cough Polio Hepb Influenzae type b
Pneumococcal Measles Mumps Rubella
Other______
Name of Family Doctor (GP)
______
4 Stand Children’s Services KidzaCool Additional Child Application Dec 2015
Consent Form Name of Child ______
I/we give my consent for Stand to: My child attending Stand Children’s Services, KidzaCool Adventures programme. YES NO Arrange necessary medical assessment and/or treatment for my child while on the YES NO KidzaCool programme Give medications necessary for general health care of my child while on the KidzaCool YES NO programme Authorise emergency medical or surgical treatment for my child should the need arise YES NO Stand to OBTAIN and RELEASE relevant information to any referring agent identified in this YES NO application which may assist with any follow-up for the child if required. Stand staff to document daily activities for the purpose of an activity report for the caregiver YES NO of the child. To my/our records being transferred (to a new designated service provider or stored YES NO confidentially by Ministry of Social Development), in the event of a change of service provider, so that I/we continue to receive this service. I/we can withdraw this consent at any time if I/we do not wish to continue with services provided by any new provider and can also request the return of my/our service file by contacting the Ministry of Social Development. My child and myself participating in a KidzaCool Adventures programme evaluation for the purpose of improving service delivery. Our child and family information being used (without identifying my child or my family) for YES NO the purpose of reviewing KidzaCool programme. My child’s photograph and/or name being used for publicity purposes if it arises. YES NO For my child to participate in appropriate activities offered at the KidzaCool Adventures YES NO programme. Special Activities: I give permission for my child to participate in the following: Boating YES NO Marae visits (sleepover) YES NO Canoe/Kayak YES NO Swimming YES NO Van trips YES NO
I understand that the Stand staff will take all reasonable steps to safeguard my child’s YES NO personal property while on the programme. However, Stand and their staff will not be held responsible for any accidental loss or damage to my child’s personal property.
If you do not have custody or guardianship, then the legal guardian must also sign this consent form. Signature Signature Date
Signature of Caregiver(s)
Signature of Legal Guardian 5 Stand Children’s Services KidzaCool Additional Child Application Dec 2015