YMCA Geelong

Please complete this form to enrol your child or children.

Family Centrelink Reference Number:

Parent Guardian Info:

Surname:

Address:

Suburb:

PCode:

Phone1:

Phone2:

Medicare:

Relationship
to Child/ren:

Email:

Emergency Contact Name:

Emergency Contact Phone:

We require your Centrelink Reference number to comply with government reporting requirements.

Please call the family assistance office on 13 61 50 if you do not have this number.

Childs CRN

Name

Children's Details

Child 1:

Child 2:

Child 3:

Child 4:

DOB

Grade

SEX

Please select the days your child/ren are attending the Holiday program.

Either select the "ALL" to indicate that your child/ren is attending all days for that week, or select individual days.

Please use the CTRL button on your keyboard to select Multiple days.

Ensure all details are correct BEFORE submitting. You can use the BACK button to recheck the information.

Child 4

Child 2

Child 3

Child 1

Week 1

Week2

Week3

Week4

Fees $35.00 per day. $4.00 late payment fee applies.
Extra Fees may apply for excursions. See program details.

Is your family is registered for Vacation Care assistance?
Please enter your percentages for 1 or more children in care.

% for 1 Child

% for 2 Child

% for 3 Child

% for 4 Child

Do you have children using Child Care
Benefits CCB's at other venues?

Do you have ambulance subscription?

Additional health cover

Do any of your child have any conditionsthat would
make participation in our program difficult?

Child 1:

Child 2:

Child 3:

Maximum Child
Care Hours:

Child 4:

Does the applicant suffer from any of the following?
Please enter child number/s. eg 1 or 1&2 etc in boxes below.

Asthma:

Epilepsy:

Diabetes:

A.D.D:

Any Medication needs for any child?

Can your child swim? If, yes please enter child number/s in box.

Arriving Time:

Depart Time:

Comments or Questions:

PARENTS/GUARDIAN Declaration: I the undersigned, approve of the above application and in doing so agree that the YMCA and its officers, leaders, staff and agents shall be released from and shall not incur, any responsibility or liability whatsoever for any accident or injury to the applicant for any damage or loss of property of the applicant. I further authorize you to obtain medical/ambulance assistance in the case of emergency involving the applicant and I agree to bear any costs thereby incurred. Furthermore, I give permission for my child to leave the centre to attend excursions for which they have enrolled and for other program activities. Yes/No

Parent/Gaurdian Name:

The YMCA acknowledges and respects privacy of individuals. The information that is being collected on this document is for the purposes of processing your membership, enrolment, providing you with updated information and assisting us improve our services to you. The intended recipients of this information are the YMCA, its authorized staff and contracted service providers. You have the right to access and alter personal information concerning yourself in accordance with the Commonwealth Privacy Act (Amended 2001) and YMCA Privacy Policy. As part of your membership with the YMCA, you will receive information from time to time regarding our programs and services. The YMCA may also provide promotional material from our strategic partners, or any other third party, if you do not wish to receives this information please write Yes in the " OPT OUT" box below and return this to the YMCA. Your name will be removed from the mailing list within a reasonable period of time. OPT OUT

Date: