Beyond the Bell Enrolment Form

BEYOND THE BELL

Out Of School Care and Holiday Programme

Child’s full legal name

Preferred name

Date of birth

Gender

Male Female

First day of attendance

Home Address

Person responsible for payment

Relationship to child

Billing address

Cell

Work phone/ext

Employer

Phone

Are you employed by Beyond the Bell

Yes No

Principal Caregiver’s name (if different to above

Relationship to child

Home Address

Home phone

Cell

Work phone/ext

The names of two people, other than the principal caregiver stated above, who (by direction of a person who has custody of the child) are allowed to collect my child or should be consulted if the child is ill or injured or contacted in any emergency situation.

Name

Relationship to child

Home phone

Cell

Work phone/ext

Name #2

Relationship to child

Home phone

Cell

Work phone/ext

N.B.: No child will be given permission to leave the centre unless the person collecting the child is noted on this form. If the person is not on this form, a written letter signed by the parent must be presented to the supervisor.

Do both parents have day to day care of the child?

YES NO

If NO, are there any parenting orders (custodial arrangements) concerning your child?

YES NO

Names of any persons who are forbidden to have any contact or restricted contact to this child (Please note: a court order needs to be sighted and a copy held on file in order for our centre to prohibit a parent/guardian from collecting his/her child.)

Name

Court Order is on file?

YES NO

We require one week’s notice in writing when changing or cancelling a child’s booking so please select your enrolment dates carefully as you will be charged for the days your child is enrolled. We do not refund any absences due to overheads incurred in anticipation of your child’s attendance.

CASUAL BOOKING

PERMANENT SCHOOL TERM BOOKING

(Indicate days required below)

CASUAL BOOKING

PERMANENT SCHOOL TERM BOOKING

Days and time Required

SCHOOL CHILD ATTENDS/WILL ATTEND

ROOM NUMBER

Child’s Doctor

Phone

In the unlikely event of a medical emergency, I understand my child will be taken to hospital in an ambulance if necessary – parents or a contact person will be notified immediately. All medical costs incurred are at the child’s Principal caregivers expense. Any child with a fever, rash, sticky eyes, diarrhoea, or vomiting is required to stay home until 48 hours after symptoms settle. I agree with the policies, and agree to adhere to them relating to my child regarding Infectious Diseases, Sick Children, Safe Pick Up and Access.

YES NO

I give permission for my child’s head to be checked for head lice by the programme manager or assistant manager. I am aware that in the case of my child having head lice, s/he may be asked to stay home until treated.

YES NO

I give permission for Arnica Cream, Bepanthen or similar to be applied to bumps and bruises.

YES NO

I give permission for the staff to apply a N.Z. approved Sun block to my child.

YES NO

I give permission for my child to be given basic First Aid treatment by the staff.

YES NO

All medications administered to your child by the centre must be handed to the supervisor on arrival at the centre and must be signed in the medication register by a parent or guardian (see Administration of Medicine Policy). For safety reasons, medication must be within the expiry date and if prescribed by a doctor, it must have the correct child’s name on it.

Does your child have any allergies (food or otherwise), religious dietary requirements, behavioural care requirements or health problems that the centre should be aware of? Please provide details and discuss with the Programme Manager (if you require more writing space please complete on a separate page & attach).

YES NO

Do you qualify for a subsidy?

YES NO

It remains your responsibility to ensure your account is paid in advance at all times and to pay any part of your fees which are not covered by a subsidy. It is your responsibility to keep Work and Income informed of any changes in circumstances or care arrangements. Always ensure your application/renewal is lodged with Work and Income prior to your child attending the programme or prior to expiry of the current subsidy. In signing this form, you agree to pay all your child’s OSCAR fees, even if your WINZ application is declined.

Unacceptable Behaviour

We have zero tolerance for physical violence, foul language and intentional damage to property or equipment. Parents/caregivers are notified of any disruption caused by their child. If the behaviour is considered a risk to others your child will be removed immediately and excluded from future attendance. In signing this form, you agree to accept the cost of any damage wilfully caused by your child and you agree to pick up your child immediately if his/her behaviour is deemed unacceptable. No refund will apply.

Fees

I agree to pay fees, as per the current fee schedule. I understand that if on an OSCAR subsidy, the child must attend the hours I have applied for. I agree to pay fees for the time booked whether my child attends or not, including Statutory Holidays falling in term time and sick days in term time and holiday programme. I agree to pay a 10% penalty (based on the amount owing) if my fees become in arrears. Late payment of fees may result in your child’s space being cancelled and all debt collection fees payable by the parent. I agree to pay a late fee if my children are left at the programme outside operating hours. This will be charged at the rate of $25 per 15 minutes, with an instant fee of $5.00. I agree to the terms and conditions on the Programme’s fee schedule. I agree to give one week’s notice in writing when changing or cancelling my child’s booking.

In the event of fees being in arrears I acknowledge a late payment fee will be charged in accordance with the current fee schedule issued by the centre. Additionally, I acknowledge I will be liable for interest on all outstanding amounts at the current rate and that all debt collection costs will be charged in addition to fees, interest and late payment charges.

The terms of this agreement are subject to the centre rules and regulations, and as such, rules and regulations may hereafter be amended from time to time. Act

Staff will do their best to ensure a safe experience for your child. However, Beyond the Bell staff and volunteers will be free and clear of all liability in the event that any injury, damage or loss is sustained to your child or their personal effects that they have brought to the programme.

I agree

My child has permission to participate in activities outside the centre which may include transport in a company approved vehicle.
YES NO

My child has permission to participate in swimming sessions.
YES NO

Swimming ability
NON-CONFIDENT CONFIDENT

I give consent for photographs to be taken of my child for publicity purposes and/or Programme activities
YES NO

I declare that the information I have provided is true and correct

Date

Information provided by parents/guardians on this enrolment form is required for statistical purposes, MSD audits, to ensure contact in an emergency and to facilitate individual care and attention for your child. Beyond the Bell follows the principles of the Privacy Act 1993. As required by the Vulnerable Children Act 2014 this information may be shared with appropriate organisations if there are any concerns for the safety of a child or another family member. .

Beyond the Bell Enrolment Form