Enrolment Form | Miri’s Créche

Please complete and submit all information below.

Enrolments will not be considered without a completed form.

Download & Print PDF Version

Child's Details










Sex:   MaleFemale

Child's date of birth:


















Is there anyone who is prohibited from having contact with or collecting the child?
YesNo

Court orders please attach:


Days required:
MonTueWedThuFri

Start date required:






Mother's Details








Mother's date of birth:
























Father's Details






Father's date of birth:

























Immunisation Details


Please supply a copy of your child's Birth Certificate and your child’s current Immunisation form. This can be accessed from your Medicare MyGov website. No other form is acceptable. This is a regulatory requirement.



Medical Details


Is your child on regular medication or have any disabilities, food sensitivities or allergies we should know about?
YesNo



Note: If yes to allergies requiring an Epipen please complete action form.

Is there any other information you wish us to know about your child?
YesNo



Has your child had any of the following?
MeaslesGerman MeaslesEar InfectionEpilepsyAsthmaHepatitisMumpsChicken PoxThroat Infection

Note: If yes to asthma please complete an asthma action form.


Emergency Details

Doctor





Release child to Doctor?
YesNo


Dentist





Release child to Dentist?
YesNo




List at least 2 people authorised to collect the child and at least 2 people that we may call if we cannot find you in an emergency. These may be the same people for both:
Person 1











Emergency release?
YesNo

Daily pick up?
YesNo




Person 2











Emergency release?
YesNo

Daily pick up?
YesNo




Person 3











Emergency release?
YesNo

Daily pick up?
YesNo





I agree that in the event of an emergency , illness or accident concerning my child and the teacher being unable to contact me or other persons so authorised by me, I consent to the Centre seeking on my behalf medical, dental, hospital & ambulance attention for my child and I accept liability for medical, dental, hospital & ambulance as may be incurred:

I agreeI do not agree

Parking Details


I have read and understood all parking requirements limitations and restrictions. I will park only in the legal parking areas and bays as permitted by the RTA and Council Requirements and Restrictions.

YesNo