Tauranga Contact us by filling out the form below. Child's DetailsChild's Official Surname or Family Name*Child's Official Given Name*Child’s Official Other Names/Middle NamesSeparatorName your child is known by/Preferred Name:Surname/Family NameGiven Name:SeparatorCopy of official identity verification document* collected by staff:*Select a form of IdentificationNew Zealand birth certificateNew Zealand PassportForeign birth certificateForeign PassportOtherFile UploadSplitterDate of Birth*Gender*Select GenderMaleFemaleOtherChild's Ethnic Origin/s*Iwi your child belongs toLanguage/s spoken at home*Child’s Primary Residential Address*Post CodeSeparatorPrivacy Statement: We are collecting personal information on this enrolment form for the purpose of providing early childhood education for your child. We will use and disclose your child’s information only in accordance with the Privacy Act 1993. Under that Act you have the right to access and request correction of any personal information we hold about your child. Details about your child’s identity will be shared with the Ministry of Education so that it can allocate a national student number for your child. This unique identifier will be used for research, statistics, funding, and the measurement of educational outcomes. You can find out more information about national student numbers at: services.education.govt.nz/eli *Information about acceptable identity verification documents is available online at services.education.govt.nz/eli The Ministry recommends that all services keep a copy of the identity verification of each child who is enrolled at the service.SplitterParent/Caregiver DetailsFirst ParentFirst Name*Surname*Home Address*Post CodeHome PhoneMobile Phone*Business PhoneEmail*Relationship to Child*OccupationSeparatorSecond Parent (Not Required)First NameSurnameHome AddressPost CodeHome PhoneMobile PhoneBusiness PhoneEmailRelationship to ChildOccupationSplitterCustodial StatementAre there any custodial arrangements concerning your child?*Please Select an OptionYesNoIf YES please give details of any custodial arrangements or court orders(a copy of any court order is required)Court Order provided to Juni Uni PreschoolPlease Select an OptionYesNoFile UploadPerson/s who cannot pick up your child:NameRelationship to childNameRelationship to childNameRelationship to childSplitterAuthorised people to pick up my child:Name*Relationship to child*SeparatorNameRelationship to childSeparatorNameRelationship to childSeparatorNameRelationship to childSeparatorNameRelationship to childSeparatorNameRelationship to childSplitterEmergency ContactsContact 1First Name*Surname*Home PhoneMobile Phone*Business PhoneRelationship to child*Contact 2First NameSurnameHome PhoneMobile PhoneBusiness PhoneRelationship to childContact 3First NameSurnameHome PhoneMobile PhoneBusiness PhoneRelationship to childContact 4First NameSurnameHome PhoneMobile PhoneBusiness PhoneRelationship to childSplitterMedicalChild's Doctor:Doctor's NamePhone NumberName of Medical CentreImmunisation:My child is up to date with immunisations*Please select an optionYesNoIf NO what immunisation is most recent?Meal Requirements:Does your child have any special dietary needs?*Please select an optionYesNoIf YES please provide detailsAllergies:Does your child have any allergies or allergic reactions?*Please select an optionYesNoIf YES, please provide details and a response for dealing with allergic reactionsMedical Conditions:Does your child have any medical conditions? E.g. Asthma, convulsions, etc*Please select an optionYesNoIf YES, please provide details and a response for dealing with medical conditionsSeparatorMedicinesCategory (i) medicines A category (i) medicine is a non-prescription preparation (such as arnica cream, antiseptic liquid, insect bite treatment) that is not ingested, and is used for the ‘first aid’ treatment of minor injuries, provided by the service and kept in the first aid cabinet.Do you approve category (i) medicines to be used on your child?*Please select an optionYesNoSeparatorCategory (ii) Medicines Category (ii) Medicines are prescription (Such as antibiotics, eye/ear drops etc) or non-prescription (such as Paracetamol Liquid, cough syrup etc) medicine that is used for a specific period of time to treat a specific condition or symptom, provided by a parent for the use of that child only or, in relation to Rongoa Maori (Maori plant medicines), that is prepared by other adults at the service. I acknowledge that written authority from a parent is to be given at the beginning of each day a category (ii) medicine is to be administered, detailing what (name of medicine), how (method and dose), and when (time or specific symptoms/circumstances) medicine is to be given.I approve category (ii) medicines to be used on my child*Please select an optionYesNoSeparatorCategory (iii) Medicines 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 eczema etc and is for the use of that child only.Name of MedicineMethod and dose of MedicineWhen does the medicine need to be taken? (State time or specific symptoms)SplitterEnrolment DetailsDate of Enrolement*Date of Entry*Date of Exit*Please note: 20 Hours ECE is for up to six hours a day, up to 20 hours per week and there must be no compulsory fees when a child is receiving 20 Hours ECE funding.SeparatorDays Enrolled:MondayTuesdayWednesdayThursdayFridayTotal Hours*For 20 Hours ECE fill out boxes below with the hours attested e.g. 6 hours20 Hours ECE at this serviceMondayTuesdayWednesdayThursdayFridayTotal Hours20 Hours ECE at another serviceMondayTuesdayWednesdayThursdayFridayTotal HoursSplitter20 Hours ECE AttestationIs your child receiving 20 ECE Hours for up to 6 hours per day, 20 hours per week at this service?*Please Select an OptionYesNoIs your child receiving 20 Hours ECE at any other services?*Please Select an OptionYesNoIf yes to either of the above, please check the box to confirm that: • Your child does not receive more than 20 hours of 20 hours ECE 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 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.Check this box to agree:*I agreeDual Enrolment Declaration: I hereby declare that my child is/is not (Select one) enrolled at another early childhood institution at the same times that he/she is enrolled at Juni Uni Preschool.Check this box to agree:*I agreeOptional Charges: 1. The Optional Charge is for: (give details of specific activities or items, and their costs) i. ii. 2. I understand that if I agree to pay for the optional charge, Juni Uni Preschool may enforce payment. 3. The agreement to pay the optional charge will last for the period of my child’s enrolment at Juni Uni Preschool. 4. I understand that the optional charge is not compulsory and if I choose not to pay there will be no penalty. 5. I agree/do not agree (select one) to pay the optional charge for the activities/items specified in this enrolment agreement formCheck this box to agree:*I agreeStatutory Holidays / Term Breaks: This enrolment agreement is inclusive of school breaks and all relevant fees will be charged accordingly. Juni Uni is closed on the following Public Holidays if they fall on a weekday or ‘Mondayisation’ applies. √ New Year’s Day √ Day After New Year’s Day √ Auckland Anniversary √ Waitangi Day √ Good Friday √ Easter Monday √ ANZAC Day √ Queen’s Birthday √ Labour Day √ Christmas Day √ Boxing DaySplitterTerms & ConditionsPermission is sought by Juni Uni Preschool to publish your child’s personal image (photo/video) or art online.*I give permission for my child’s first name, photograph/video, or work to be published on the Juni Uni website, facebook page or in the newsletter.SeparatorChild's Name*Relationship to Child*Please select applicableParentLegal GuardianCaregiverName*Check this box to agree:*I agreeI/ We give permission To Juni Uni management and staff to: • Carry out written observations and use digital images of my child for purposes of programme planning, centre displays, and promotion. • Take my child out of the centre on spontaneous short walks in accordance with our excursion policy the adult to child ratio is 1:4 • Apply sunscreen for outdoors. • Allow the persons listed as Emergency Contacts to sign off the Medication and Accident forms. I / We agree: • To pay all fees 1 week in advance by Automatic Payment, online banking or cash. • That if my fees are not paid in advance or are in arrears for more than 1 week my account will be charged a late penalty rate of $10 per week, and if no arrangements have been made with Management, my child’s place may be withdrawn. • That full fees will be charged for all bookings made, regardless of attendance. • On acceptance of my child into Juni Uni, an enrolment pack (cost of $30) will be purchased. • In order to meet Ministry requirements my child may initially be conditionally enrolled and will be eligible to attend in the place of an absent enrolled child • Once enrolled, absences due to illness or otherwise will be paid for with no exceptions. • Full fees will be paid for all public holidays and any other holidays taken from Juni Uni. (WINZ does not pay for public holidays; therefore I/We agree to pay for public holidays). • Late pick-ups will be charged in accordance with the fee policy. • All early drop-offs or late pick-ups will be charged as late fees. • To sign the register upon drop off and pick up of my child, each day that they attend. • That any changes to my child’s booked times will be made by close of business the week prior on the forms provided next to the sign in sheet. I will then sign the attestation form provided by management. • Additional charges may apply to excursions or special events etc. to be paid in advance. • Management reserves the right to withdraw or change a child’s enrolment status at any time and I/we consent to such changes being made at the sole discretion of management. • That we understand and will abide by Juni Uni policies and procedures as set out in the Policies & Procedures Manual. • To be eligible for 20 ECE hours an attestation form must be signed exclusively for all 20 ECE hours. • To provide 2 weeks written notice prior to withdrawing my child from Juni Uni and agree to pay all outstanding fees prior to my child’s departure. To be responsible for any outstanding fees and any costs incurred to Juni Uni in collecting these outstanding fees.Parent Declaration:I declare that all the above information is true and correct to the best of my knowledge To be signed and dated in centreSend Error occured. 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