Dentist Name: Phone Number: Dentist Address: Private Health: Provider and Membership No. □ □ Yes No Ambulance Subscription Do you provide authorisation □ □ □ □ Yes No Yes No for the child to self-administer medication? Do you give consent for the Do you give consent for the □ □ □ □ Yes No Yes No service to seek medical service to seek transportation treatment for the child from of the child by an ambulance a registered medical service? practitioner, hospital or ambulance service? Has your child been If yes, to what? □ □ Yes No diagnosed at risk of (Please provide medical Anaphylaxis management plan) Does your child have any If yes, to what? □ □ Yes No allergies? (Please provide medical e.g. food, medication, management plan if animals insects? applicable) Does your child have any If yes, please explain □ □ Yes No special dietary requirements? Does your child have any If yes, please explain □ □ Yes No problems with hearing, sight, speech? Does your have any If yes, please explain □ □ Yes No health problems, (Please provide medical operations, illnesses, management plan if disabilities? applicable), Does your child have If yes - (Please provide □ □ Yes No asthma? medical management plan) Does your child take any If yes please explain – □ □ Yes No regular medication? Does your child have a If yes please explain. (Please – □ □ Yes No physical disability or delay, provide medical management including intellectual, plan if applicable) sensory or physical impairment? Does either parent have a Is the family a single parent □ □ □ □ Yes No Yes No disability? family? Please provide further information to the above medical questions if applicable. IF YOU HAVE INDICATED A MEDICAL CONDITION ABOVE PLEASE ENSURE THAT YOU HAVE COMPLETED A MEDICAL MANAGEMENT PLAN WITH THIS ENROLMENT. ROUTINES Has your begun toilet Is your child used to being □ □ □ □ Yes No Yes No training? with other children? Is your child used to being Is this the first time your child □ □ □ □ Yes No Yes No with other adults? has been cared for by someone other than a family member? Are there any aspects of Are there any special □ □ □ □ Yes No Yes No your child’s cultural, ethnic, considerations for your child? and/or religious background Eg. cultural, religious or additional needs?
Dentist Name: Phone Number: Dentist Address: Private Health: □ Yes □ No Provider and Membership No. Ambulance Subscription □ Yes □ No Do you provide authorisation for the child to self-administer medication? □ Yes □ No Do you give consent for the service to seek medical treatment for the child from a registered medical practitioner, hospital or ambulance service? □ Yes □ No Do you give consent for the service to seek transportation of the child by an ambulance service? □ Yes □ No Has your child been diagnosed at risk of Anaphylaxis □ Yes □ No If yes, to what? (Please provide medical management plan) Does your child have any allergies? e.g. food, medication, animals insects? □ Yes □ No If yes, to what? (Please provide medical management plan if applicable) Does your child have any special dietary requirements? □ Yes □ No If yes, please explain Does your child have any problems with hearing, sight, speech? □ Yes □ No If yes, please explain Does your have any health problems, operations, illnesses, disabilities? □ Yes □ No If yes, please explain (Please provide medical management plan if applicable), Does your child have asthma? □ Yes □ No If yes - (Please provide medical management plan) Does your child take any regular medication? □ Yes □ No If yes – please explain Does your child have a physical disability or delay, including intellectual, sensory or physical impairment? □ Yes □ No If yes – please explain. (Please provide medical management plan if applicable) Does either parent have a disability? □ Yes □ No Is the family a single parent family? □ Yes □ No Please provide further information to the above medical questions if applicable. IF YOU HAVE INDICATED A MEDICAL CONDITION ABOVE PLEASE ENSURE THAT YOU HAVE COMPLETED A MEDICAL MANAGEMENT PLAN WITH THIS ENROLMENT. ROUTINES Has your begun toilet training? □ Yes □ No Is your child used to being with other children? □ Yes □ No Is your child used to being with other adults? □ Yes □ No Is this the first time your child has been cared for by someone other than a family member? □ Yes □ No Are there any aspects of your child’s cultural, ethnic, and/or religious background □ Yes □ No Are there any special considerations for your child? Eg. cultural, religious or additional needs? □ Yes □ No
child_enrolment_form_-_parent_handbook_june_2017.docx