Drop Off Service
Drop Off Service (General Supervised Care) AGES 5 – 11 Years Kids Must Wear Socks At All Times Parent / Caregiver Details: Full name: Address: Home phone: Child/s Name: 1) 2) 3)
Mother / Father / Grandparent /Aunt /Uncle / Friend / Other: Post code: Place of work: Mobile: Work: D.O.B: 4) D.O.B: D.O.B: 5) D.O.B: D.O.B: 6) D.O.B:
Emergency contact details Full name: Address: Home phone:
NEEDS TO BE ANOTHER PERSON OTHER THAN YOURSELF!!!! Mother / Father / Grandparent /Aunt /Uncle / Friend / Other: Post code: Place of work: Mobile: Work:
Medical Details: If your child suffers ( even slightly) from any of the following , please indicate where applicable & record details below. Asthma/Allergy
Diabetes
ADD
Epilepsy
Recurring Injuries
Other:
Or circle NO Medical Conditions (please provide relevant details below:)
Attendance details:
Drop Off Time:
Expected Pickup Time:
Actual Pickup Time:
SIGN OUT:
NOTE: An Additional Charge of $4.00 per hour or part thereof will apply to any late pickups. Purchases: I leave my child $ to spend on snacks or drinks. My child is or isn’t allowed to have: (please cross what you don’t want them eating and circle what you do want them to have. Food Products Lollies ice blocks Drinks Fizzy chocolate Anything Waiver: (please read and sign) I/We understand that chipmunks is providing general supervision but the ultimate responsibility of the children’s behavior is the parents responsibility, chipmunks reserves the right to terminate or instigate departure of any child or parent who are not follow the rules, staff instructions or participating in dangerous play. I acknowledge my child enters chipmunks at their own risk and chipmunks takes no responsibility for any article of footwear clothing or property that goes missing from the center. this does not affect any right I have under the consumer guarantee act 1993. I/We confirm that all the information supplied is true and i/we accept the rules & Regulations of chipmunks as set out within the center. I lastly confirm my child is at least 5 years of age and has socks to wear while playing at chipmunks if not I agree to be charged for the purchase of socks for my child/ren.
Parent / Caregiver Signature: Office use only: comments: Problems issues or injuries:
Date:
Mother / Father / Grandparent /Aunt /Uncle / Friend / Other: Post code: Place of work: Mobile: Work: D.O.B: 4) D.O.B: D.O.B: 5) D.O.B: D.O.B: 6) D.O.B:
Emergency contact details Full name: Address: Home phone:
NEEDS TO BE ANOTHER PERSON OTHER THAN YOURSELF!!!! Mother / Father / Grandparent /Aunt /Uncle / Friend / Other: Post code: Place of work: Mobile: Work:
Medical Details: If your child suffers ( even slightly) from any of the following , please indicate where applicable & record details below. Asthma/Allergy
Diabetes
ADD
Epilepsy
Recurring Injuries
Other:
Or circle NO Medical Conditions (please provide relevant details below:)
Attendance details:
Drop Off Time:
Expected Pickup Time:
Actual Pickup Time:
SIGN OUT:
NOTE: An Additional Charge of $4.00 per hour or part thereof will apply to any late pickups. Purchases: I leave my child $ to spend on snacks or drinks. My child is or isn’t allowed to have: (please cross what you don’t want them eating and circle what you do want them to have. Food Products Lollies ice blocks Drinks Fizzy chocolate Anything Waiver: (please read and sign) I/We understand that chipmunks is providing general supervision but the ultimate responsibility of the children’s behavior is the parents responsibility, chipmunks reserves the right to terminate or instigate departure of any child or parent who are not follow the rules, staff instructions or participating in dangerous play. I acknowledge my child enters chipmunks at their own risk and chipmunks takes no responsibility for any article of footwear clothing or property that goes missing from the center. this does not affect any right I have under the consumer guarantee act 1993. I/We confirm that all the information supplied is true and i/we accept the rules & Regulations of chipmunks as set out within the center. I lastly confirm my child is at least 5 years of age and has socks to wear while playing at chipmunks if not I agree to be charged for the purchase of socks for my child/ren.
Parent / Caregiver Signature: Office use only: comments: Problems issues or injuries:
Date:
