Koraunui Care Centre Enrolment Form

The Children

Child One's Name

Child One's Date of Birth

Child Two's Name

Child Two's Date of Birth

Child Three's Name

Child Three's Date of Birth

Caregiver One

Caregiver One Name

Caregiver One Home Address

Caregiver One Daytime Contact

Caregiver One Evening Contact

Caregiver One Cellular Phone number

Caregiver One Relationship to Child/ren

Caregiver Two

Caregiver Two Name

Caregiver Two Home Address

Caregiver Two Daytime Contact

Caregiver Two Evening Contact

Caregiver Two Cellular Phone number

Caregiver Two Relationship to Child/ren

People Authorised To Collect Your Children

Name of authorised person 1

Name of authorised person 2

Name of authorised person 3

Emergency Contacts

Emergency contacts other than parents (This is a legal requirement)

Contact One's Name

Contact One's Contact Number

Contact One's Relationship to Child/ren

Contact Two's Name

Contact Two's Contact Number

Contact Two's Relationship to Child/ren

Medical

Doctor's Name

Doctor's Phone Number

Does your child have any health needs that may require special attention?

Access Arrangements

Are there any special instructions regarding access?

Is there anything else we should know about in order to take good care of your child/ren?

Legal

UNACCOMPANIED RELEASE:

I authorise Koraunui Care Centre to release my child/ren to walk/ride home on their own or leave KCC to attend a sports practice etc. I am aware that it is my responsibility to contact the Care Centre when I wish this to happen and I acknowledge that neither the staff nor management of the programme will be liable for any loss, damage (by way of accident, injury, theft or otherwise) arising from this authorization.

Release Permission

Yes

SOLE CHARGE STAFFING

During the programme when numbers are 7 or lower, we may only have one staff member on duty. In the case of an emergency there will be a back-up person available at short notice. Please indicate you have read and understood this.

I have read and understand the sole charge information

Yes

DIGITAL IMAGE PERMISSION:

During the programme, photos of your child/ren may be taken and used in the school newsletter, local newspaper items, the school website and wider publications i.e. the OSCAR newsletter which is available nationwide. Do you give permission for such photos to be used?

I give permission for digital images of my child to be used

Yes

Our charges are $12.00 for the afternoon session, $60.00 for the week and $7.00 for the morning session, $35.00 for the week and $17.00 a day if your child attends both the morning and afternoon session in the same day, $85.00 for the whole week. There is a $14.00 a session charge for casual afternoon bookings and $9.00 for morning sessions. If you have a permanent booking you will be charged for the sessions your child/ren is/are booked in for, whether or not they attend (this includes public holidays). Any charges incurred in recovering outstanding fees will be passed on to the parent/caregiver.

Please indicate your method of payment and which day this will begin. If you require a WINZ form, please let the Supervisor know. If you require an automatic payment form, please let the Supervisor know.

METHOD OF PAYMENT

Please select the payment method you prefer

WINZ

CASH / CHEQUE

AUTOMATIC PAYMENT

OTHER

Method of payment if other:

DAYS OF CARE REQUESTED

Agreement Acknowledgment

All care will be taken to provide supervision of children attending the programme in accordance with the programme policy and procedures. I can at any time, read the full policies that are available at Care Centre. I am aware of the late fee applicable should I not pick up my child/ren by 5.45pm and that any charges incurred in recovering outstanding fees will be passed on to the me.

I acknowledge however, in signing this form, that neither the staff nor management of the programme will be liable for any loss or damage (by way of accident, injury, theft or otherwise) arising out of attendance at the programme.

Any personal information supplied will be kept secure and will not be disclosed to any third party. Any personal information supplied will only be used for the purpose for which it was provided or permitted by the Privacy Act 2020 or otherwise required by law. Any information gathered may be viewed by the Ministry of Social Development for audit purposes, in line with the Privacy Act 2020, personal information required to be utilised that relate to any unpaid fees, can be passed to a debt collection agency and/or department of courts.

In addition I confirm in submitting this form that I have read agree to abide by the Koraunui Care Centre terms and conditions.

I AGREE AND ACKNOWLEDGE:

Yes

Name of Caregiver

Date of agreement acknowledgment

email address

We wish to decrease the amount of spam we get.

Please type the letters at the top of the image at the left in the next field and then click submit.

Without this the notification will not go through.

PLEASE TYPE YOUR ANSWER IN CAPITAL LETTERS