Enrolment Agreement Form
Acorn Pre School
  1. Child:
  2. Child's first names:(*)
    Please type Chile first name.
  3. Surname:
    Invalid Input
  4. Name your child is known by:(*)
    Please type Chile first name.
  5. Child's date of birth(*)
    Please select the date of birth of the child.
  6. Gender(*)
    Please specify gender of the child.
  7. Ethnic Origin:(*)
    Please type Ethnic Origin.
  8. Lwi your child belongs to:(*)
    Please type lwi your child belongs to.
  9. Child's home address or addresses:
    Invalid Input
  10. Postalcode:
    Invalid Input
  11.  
  1. Parents / Guardians:
  2. First Names:
    Invalid Input
  3. Surname:
    Invalid Input
  4. Address:
    Invalid Input
  5. Postcode:
    Invalid Input
  6. Phone (Home):
    Invalid Input
  7. Phone (Work):
    Invalid Input
  8. Phone (Mobile):
    Invalid Input
  9. Email:
    Invalid Input
  10. First Names:
    Invalid Input
  11. Surname:
    Invalid Input
  12. Address:
    Invalid Input
  13. Postcode:
    Invalid Input
  14. Phone (Home):
    Invalid Input
  15. Phone (Work):
    Invalid Input
  16. Phone (Mobile):
    Invalid Input
  17. Email:
    Invalid Input
  18.  
  1. Emergency Contacts:
  2. First Names:
    Invalid Input
  3. Surname:
    Invalid Input
  4. Address:
    Invalid Input
  5. Postcode:
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  6. Phone (Home):
    Invalid Input
  7. Phone (Work):
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  8. Phone (Mobile):
    Invalid Input
  9. Email:
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  10. First Names:
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  11. Surname:
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  12. Address:
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  13. Postcode:
    Invalid Input
  14. Phone (Home):
    Invalid Input
  15. Phone (Work):
    Invalid Input
  16. Phone (Mobile):
    Invalid Input
  17. Email:
    Invalid Input
  18.  
  1. Doctor:
  2. Name:
    Invalid Input
  3. Phone:
    Invalid Input
  4. Address:
    Invalid Input
  5.  
  1. Enrollment Details:
  2. Date of enrolment:
    Invalid Input
  3. Date of entry:
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  4. Date of exit:
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  5. 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.
  6. Days Enrolled:
    Monday
    Tuesday
    Wednesday
    Thursday
    Friday
     
    Times Enrolled:
  7. Invalid Input
  8. Invalid Input
  9. Invalid Input
  10. Invalid Input
  11. Invalid Input
  12. Total Number of Hours
  13. For 20 Hours ECE fill out boxes below with the hours attested ef. 6 hours
  14. 20 Hours ECE at this Service
  15. Invalid Input
  16. Invalid Input
  17. Invalid Input
  18. Invalid Input
  19. Invalid Input
  20. Total Number of Hours
    20 Hours ECE at this Service
  21. Invalid Input
  22. Invalid Input
  23. Invalid Input
  24. Invalid Input
  25. Invalid Input
  26. Total Number of Hours
  27. Parent / Guardian Signature:
    Invalid Input
  28. Date:
    Invalid Input
  29.  
  1. 20 Hours ECE Attestation:
  2. Is your child receiving 20 Hours ECE for up to six hours per day, 20 hours per week at this service:
    Invalid Input
  3. Is your child receiving 20 Hours ECE at any other service:
    Invalid Input
  4. 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 HCE 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.
  5. Parent / Guardian Signature:
    Invalid Input
  6. Date:
    Invalid Input
  7.  
  1. Dual Enrolment Declaration:
  2. I hereby declare that my child is not enrolled at another early childhood institution at the same times that he/she is enrolled at Acorn preschool.
  3. Parent / Guardian Signature:
    Invalid Input
  4. Date:
    Invalid Input
  5.  
  1. Custodial Statement
  2. Are there any custodial arrangements concerning your child?
    Invalid Input
  3. If YES,please give details of any custodial arrangements or court orders (a copy of any court order is required)
    Invalid Input
  4. Person/s who cannot pick up your child:
  5. Name:
    Invalid Input
  6. Name:
    Invalid Input
  7. Name:
    Invalid Input
  8. Name:
    Invalid Input
  9. Person/s who can pick up your child:
  10. First Names:
    Invalid Input
  11. Surname:
    Invalid Input
  12. Address:
    Invalid Input
  13. Postcode:
    Invalid Input
  14. Phone (Home):
    Invalid Input
  15. Phone (Work):
    Invalid Input
  16. Phone (Mobile):
    Invalid Input
  17. First Names:
    Invalid Input
  18. Surname:
    Invalid Input
  19. Address:
    Invalid Input
  20. Postcode:
    Invalid Input
  21. Phone (Home):
    Invalid Input
  22. Phone (Work):
    Invalid Input
  23. Phone (Mobile):
    Invalid Input
  24. First Names:
    Invalid Input
  25. Surname:
    Invalid Input
  26. Address:
    Invalid Input
  27. Postcode:
    Invalid Input
  28. Phone (Home):
    Invalid Input
  29. Phone (Work):
    Invalid Input
  30. Phone (Mobile):
    Invalid Input
  31. First Names:
    Invalid Input
  32. Surname:
    Invalid Input
  33. Address:
    Invalid Input
  34. Postcode:
    Invalid Input
  35. Phone (Home):
    Invalid Input
  36. Phone (Work):
    Invalid Input
  37. Phone (Mobile):
    Invalid Input
  38.  
  1. Health
  2. Illness / allergies:
  3. Is your child up-to-date with immunisations:
    (Please provide verifications of all immunisations
    Invalid Input
  4. Immunisations record sighted and details recorded:
    Invalid Input
  5.  
  1. Medicine
  2. Category (i) Medicines
  3. A Category (i) medicine is a non-prescription preparation (such as arnica cream, antiseptic liquid, insect bit 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
  4. Do you approve category (i) medicines to be used on your child?
    Invalid Input
  5. Name's of specific category (i) medicines that can be used on my child, provided by the service:
  6. Invalid Input
  7. Invalid Input
  8. Invalid Input
  9. Invalid Input
  10. Parent / Guardian Signature:
    Invalid Input
  11. Date:
    Invalid Input
  12. Category (ii) Medicines
  13. 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 exzema etc and is for the use of that child only
  14. Individual health plan completed and signed:
    Invalid Input
  15. Name of Medicine:
    Invalid Input
  16. Method and dose of Medicine:
    Invalid Input
  17. When does the medicine need to be taken: (State time or specific symptoms)
    Invalid Input
  18. Parent / Guardian Signature:
    Invalid Input
  19. Date:
    Invalid Input
  20.  
  1. I have read and understand the following:
    • I have read the Child Protection Policy
    • I will not bring my child to the centre if he/she is ill or suffering from any of the following infection diseases: measles, chicken pox,mumps, impetigo, conjunctivitis,gastroenteritis,hand,foot and mouth disease, or has vomited in the last 48 hours
    • I will notify the centre if anyone other than those listed above is to pickup up my child from the centre
    • I will notify the centre of any changes to contact details
    • I will notify the centre if my child attends at a time when he/she is normally enrolled at another Early Childhood Centre
    • I have read and agree with the sleep room policy
    • I have read and understood the fee policy
    • I am aware that centre policies are kept in the operations manual in the foyer and i agree to abide to these policies
  2. Parent / Guardian Signature:
    Invalid Input
  3.  
  1. Parent Declaration
  2. I declare that all the above information is true and correct to the best of my knowledge
  3. Parent / Guardian Signature:
    Invalid Input
  4. Date:
    Invalid Input
  5.  
  1. Service Declaration
  2. On behalf of Acorn preschool, i declare that this form has been checked and all relevant sections have been completed
  3. Service Provider Signature:
    Invalid Input
  4. Date:
    Invalid Input
  5.  
  1. Change of Days/Times of Enrolment:
  2. Effective date of change:
  3. Days Enrolled:
    Monday
    Tuesday
    Wednesday
    Thursday
    Friday
     
    Times Enrolled:
  4. Invalid Input
  5. Invalid Input
  6. Invalid Input
  7. Invalid Input
  8. Invalid Input
  9. Total:
  10. For 20 Hours ECE fill out boxes below
  11. 20 Hours ECE at this service
  12. Invalid Input
  13. Invalid Input
  14. Invalid Input
  15. Invalid Input
  16. Invalid Input
  17. 20 Hours ECE at another service
  18. Invalid Input
  19. Invalid Input
  20. Invalid Input
  21. Invalid Input
  22. Invalid Input
  23.  
  24. Parent / Guardian Signature:
    Invalid Input
  25. Date:
    Invalid Input
  26. Anti Spam
    Anti Spam
    Invalid Input

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