Enrolment form

Child's details

Child's official name*

Given name Middle Family/Surname

Name your child is known by / preferred name:*

Given name Family/Surname

Child's date of birth*

Gender*

Child’s ethnic origin/s:*

Language/s spoken at home:*

Iwi your child belongs to:

Child’s primary residential address:*

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: 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.

Parent / Guardian 1

Name*

First Last

Address*

Phone (home)*

Phone (work)

Phone (mobile)

Email*

Relationship to child*

Occupation

Parent / Guardian 2

Name

First Last

Address

Phone (home)

Phone (work)

Phone (mobile)

Email

Relationship to child

Occupation

Additional person/s who can pick up your child

Person 1

Person 1 Name

First Last

Person 1 address

Person 1 Phone (home)

Person 1 Phone (work)

Person 2

Person 2 Name

First Last

Person 2 address

Person 2 Phone (home)

Person 2 Phone (work)

Custodial statement

Are there any custodial arrangements concerning your child?*

Yes

No

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:

Person 1 name

Person 2 name

Person 3 name

Person 4 name

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

MUST COMPLETE SUPPLY AT LEAST ONE EMERGENCY CONTACT.

Person 1

Person 1 Name*

First Last

Person 1 address*

Person 1 phone (home)*

Person 1 phone (work)

Person 1 phone (mobile)

Person 1 Relationship to child*

Person 2

Person 2 Name

First Last

Person 2 address

Person 2 phone (home)

Person 2 phone (work)

Person 2 phone (mobile)

Person 2 Relationship to child

Person 3

Person 3 Name

First Last

Person 3 address

Person 3 phone (home)

Person 3 phone (work)

Person 3 phone (mobile)

Person 3 Relationship to child

Child's doctor

Doctor's name*

Doctor's phone*

Name of medical centre*

Health

Illness/allergies

Is your child up-to-date with immunisations?*

Yes

No

(Please provide verification of all immunisations)

Category (i) Medicines

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?*

Yes

No

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

Arnica cream (to prevent bruising)

Insect bite treatment

Sunscreen

Antiseptic treatment

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.

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.

Name of medicine

Method and dose of medicine:

When does the medicine need to be taken: (State time or specific symptoms)

Enrol your child today

Child's details

Privacy statement

Parent / Guardian 1

Parent / Guardian 2

Additional person/s who can pick up your child

Person 1

Person 2

Custodial statement

Person/s who cannot pick up your child:

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

Person 1

Person 2

Person 3

Child's doctor

Health

Category (i) Medicines

Category (ii) Medicines

Category (iii) Medicines

Enrolment details

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

20 Hours ECE Attestation: