Minimee Early Learning Limited

09 418 2770
manager@minimee.co.nz
6 Bank Street, Hillcrest, Auckland 0627, New Zealand

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Enrollement Form

Child Details
Parent Details
Health
Enrolment Details
Declaration

Child Details

Reference:

NSN:

Child's official surname or family name: *

Child's official given name:

Child's official other names / middle names:

Name your child is known by / preferred name:

Surname / family name:

Given Name:

Copy of official identity verification document sighted by staff:

New Zealand birth certificate

Foreign birth certificate

New Zealand passport

Foreign passport

Other

Staff Initials:

Child's Date of Birth

Child's Gender

Male

Female

Child's ethnic origin/s:

Iwi your child belongs to:

Language/s spoken at home:

Child's primary residential address:

Privacy Statement

All early childhood services must meet their responsibilities under the Privacy Act 2020, which include providing a Privacy statement on enrolment agreements which meets the requirements of that Act (see Principle 3 - Collection of information from subject). Additionally, all Privacy statements must include the exact wording below:

Personal information about your child collected on this enrolment form is shared with the Ministry of Education who store it securely and treat it in accordance with the Privacy Act 2020.

Information is disclosed to the Ministry:

for funding allocation purposes
for monitoring purposes
to allow the assignment of a National Student Number* to your child, and
to allow the Minister or Secretary of Education to exercise any of their other powers or responsibilities under the Education and Training Act 2020, and as permitted by Privacy Principles 10 and 11.

Completed forms may also be viewed by Ministry officials on request for the purposes of monitoring and licensing.

* A National Student Number is a unique identifier for your child within the education system. You can find more information about National Student Numbers and what they are used for at National Student Number (NSN) » NZQA

Early childhood services can find out more information about NSN assignment – including acceptable identity verification documents – at: National Student Numbers (NSN) – Education in New Zealand

The Ministry recommends keeping a record of identity verification documents that have been sighted, but not retaining copies of identity verification documents, which if received, should be securely destroyed once verified.

PARENT / GUARDIANS

1. Given names:

Surname / family name:

Address:

Phone (Home):

Phone (Work):

Phone (Mobile):

Email:

Relationship to child:

Occupation:

2. Given names:

Surname / family name:

Address:

Phone (Home):

Phone (Work):

Phone (Mobile):

Email:

Relationship to child:

Occupation:

Additional Person/s who can pick up your child

1. Given names:

Surname / family name:

Address:

Phone (Mobile):

Relationship to child:

2. Given names:

Surname / family name:

Address:

Phone (Mobile):

Relationship to child:

EMERGENCY CONTACTS

Add emergency contact(s) other than Parent/Guardian - (Also able to pick up your child)

1. Given names:

Surname / family name:

Address:

Phone (Mobile):

Relationship to child:

2. Given names:

Surname / family name:

Address:

Phone (Mobile):

Relationship to child:

Custodial Statement:

Are there any custodial arrangements concerning your child? Please Circle:

Yes No

If YES, please give details of any custodial arrangements or court orders. (a copy of any court order is required).

Person/s who cannot pick up your child:

1. Name:

2. Name:

3. Name:

4. Name:

Please advise us immediately if there are any changes to custodial arrangements concerning your child, or to the persons who cannot pick up your child, including because of court orders.

HEALTH

Child's Doctor

Name and Address of Medical Centre:

Doctor’s Name:

Phone:

Child’s Health:

Illness/allergies:

Food your child cannot eat:

Is your child up to date with immunisations?

Yes No

For staff: Immunisation records sighted, and details recorded:

Yes No

Medicines

About your child

Our centre is committed to inclusive education, as per Te Whāriki and the National Education and Learning Priorities (NELP), in particular with reference to Objective 1: Learners at the centre and Objective 2: Barrier free access. This commitment includes working with families and whānau to find ways to reduce barriers to education for disabled learners and those with learning support needs.

If your child has an illness or condition, what are the implications or actions to be taken in relation to the child’s illness or condition. For example, does the child’s illness or condition require an individual health plan?

For this purpose, please indicate whether you would like to book a meeting to share any health, wellbeing, and/or education and child development information with the centre. This will assist the centre to help your child settle in as well as possible and receive the appropriate health care.

I would like to book a meeting in to discuss my child’s individual health plan.

Yes No

ENROLLEMENT DETAILS

Date of Enrolment:

Date of Entry:

Date of Exit:

Please Note: 20 Hours ECE is for up to six hours per day, up to 20 hours per week and there must be no compulsory fees when a child is receiving 20 Hours ECE funding.

For 20 Hours ECE fill out boxes below with the hours attested e.g. 6 hours

Parent/Guardian Signature:

Date:

20 Hours ECE Attestation:

DECLARATION

Statutory Holidays / Term Breaks

I declare that all the above information is true and correct to the best of my knowledge.

Parent/Guardian Signature: *

Date:

Service Declaration

On behalf of Minimee Early Childhood Adventure I declare that this form has been checked and all relevant sections have been completed.

Service Provider Signature:

Date:

Enrollement Form

Child Details

Privacy Statement

PARENT / GUARDIANS

1. Given names:

2. Given names:

Additional Person/s who can pick up your child

1. Given names:

2. Given names:

EMERGENCY CONTACTS

Add emergency contact(s) other than Parent/Guardian - (Also able to pick up your child)

1. Given names:

2. Given names:

Custodial Statement:

Person/s who cannot pick up your child:

Please advise us immediately if there are any changes to custodial arrangements concerning your child, or to the persons who cannot pick up your child, including because of court orders.

HEALTH

Child's Doctor

Child’s Health:

Medicines

Category (i) Medicines

Name/s of specific category (i) medicines that can be used on my child:

Category (ii) Medicines

Category (iii) Medicines

About your child

ENROLLEMENT DETAILS

Dual Enrolment Declaration

Family Boost Rebate Scheme

Work and Income Childcare Subsidy

Absences

Statutory Holidays / Term Breaks

Required Information for Licensing Purposes

Other information

DECLARATION

Statutory Holidays / Term Breaks

Service Declaration

Minimee Early Learning

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