Medication Authority

Medication Authority
CONFIDENTIAL

To be completed by the AUTHORISED PRESCRIBER and the PARENT/GUARDIAN.
This information is confidential and will be available only to supervising staff and emergency medical personnel.
Name of child
Family name (please print)
Date of birth
Date Format: MM slash DD slash YYYY
MedicAlert Number (if relevant)
Date for next review
Date Format: MM slash DD slash YYYY
Allergies
Note: Medication authorities can be endorsed by the following: medical practitioners (GPs and/or specialists), dentists, ophthalmologists, nurse practitioners, pharmacists
Please:
- Complete all sections of this form. This is a single medication sheet. Please use a separate form for each medication.
- This medication form is appropriate for bothlong-term and short-term medication e.g. antibiotics. Schedule medication outside care hours whenever possible.
- Be specific: As needed is not sufficient direction for staff members – they need to know exactly when medication is required.
- Nominate the simplest method. For example: Oral or ‘puffer’ medication is much easier to arrange than a nebuliser.
Please note that childcare workers:
- Accept only medication which has been ordered by an authorised prescriber and is provided in the original, fully labelled pharmacy container
- Do not monitor the effects of medication as they have no training to do this,
- Are instructed to seek emergency medical assistance if concerned about a person’s behaviour following medication.
MEDICATION INSTRUCTION
Medication name (include generic name)
Form (e.g. liquid, tablet, cream)
Route (e.g. oral, inhaled, topical)
Strength
Dose
Other instructions for administration
Start/finish date (if appropriate) from
Date Format: MM slash DD slash YYYY
To
Date Format: MM slash DD slash YYYY
TIME
Please tick administration time(s)
Time
- 7:30 - 8:30 am
- 9 – 10:30 am
- 11 – 12:30 am
- 1 – 2:30 pm
- 3 – 4:30 pm
- 5 – 6:15 pm
This plan has been developed for the following setting:
- Childcare
- Excursion
AUTHORISATION AND RELEASE
Authorised prescriber
Professional role
Address
Telephone
Signature*
Date
Date Format: MM slash DD slash YYYY
I have read, understood and agreed with this plan and any attachments indicated above.
I approve the release of this information to supervising staff and emergency medical personnel.
Parent/guardian
Signature*
Date
Date Format: MM slash DD slash YYYY

Enrol Your Child

Enrolment Form

Form for new enrolments to the centre

Step 1 of 9

Child's Name*
First Name Family Name Other
Known As*
Gender*
Primary Language*
Date of Birth*
Date Format: DD dash MM dash YYYY
Birth Certificate Cited*
CRN*
Address*
Street Address Address Line 2 City State Postcode
Indigenous Status
Aboriginal*
Torres Strait Islander*

Eligible Parent/Guardian & Billing Details
Name*
First Name Family Name
Date of Birth*
Date Format: DD dash MM dash YYYY
CRN*
Relationship to Child*
Contact Priority*
Please enter a number from 0 to 5.
Primary Language*
Home Address*
Street Address Address Line 2 City State Postcode
Work Address*
Street Address Address Line 2 City State Postcode
Home Phone*
Work Phone*
Mobile Phone*

Other Parent/Guardian If Applicable
Name*
First Name Family Name
Date of Birth*
Date Format: DD dash MM dash YYYY
CRN*
Relationship to Child*
Contact Priority*
Please enter a number from 0 to 5.
Primary Language*
Home Address*
Street Address Address Line 2 City State Postcode
Work Address*
Street Address Address Line 2 City State Postcode
Home Phone*
Work Phone*
Mobile Phone*

Emergency Contacts and Collection Authorities
Name*
First Name Family Name
Relationship to Child*
Contact Priority*
Please enter a number from 0 to 5.
Home Phone*
Work Phone*
Mobile Phone*
Section Break
Name*
First Name Family Name
Relationship to Child*
Contact Priority*
Please enter a number from 0 to 5.
Home Phone*
Work Phone*
Mobile Phone*
It is very important that you let these people know that you have nominated them. In nominating them you give them authority to act on the child's behalf if neither parent can be located, to pick up the child in an emergency and care for the child until she can be returned home.

Collection Authorities Only
Name*
First Name Family Name
Relationship to Child*
Home Address*
Street Address Address Line 2 City State Postcode
Home Phone*
Work Phone*
Mobile Phone*
Section Break
Name*
First Name Family Name
Relationship to Child*
Home Address*
Street Address Address Line 2 City State Postcode
Home Phone*
Work Phone*
Mobile Phone*
The people nominated have been given approval ONLY to collect the child and should NOT be contacted in an emergency.

Booking Preferences
Monday*
Tuesday*
Wednesday*
Thursday*
Friday*
Period of Attendance*
From...*
Date Format: DD dash MM dash YYYY
For...
Amount of weeks..
...or until
Date Format: DD dash MM dash YYYY

UNIVERSAL ACCESS DATA COLLECTION

Does the parent/guardian/carer of this child have any of the following?
Health Care Care*
Pensioner Concession Card*
Temporary Protection/Humanitarian Visa*
Bridging Visa for an Asylum Seeker*
Department of Veterans Affairs Gold Card*
If this child attends another funded Preschool program please complete the following:
Name of other Preschool/Kindergarten
How many hours of attendance at other Preschool/Kindergarten
Please enter a number from 0 to 40.

Number
PARENTING PLANS/ORDERS relating to this child*

IS THERE ANYTHING MORE WE NEED TO KNOW?
e.g., any personal, religious or cultural practices/prohibitions that you would like the service to know?

Annual Parent Information

Parent Information Annual Update

Annual information for our records to ensure everything is up to date

Your Child's Information
Children at RPCC*
How many children do you have at RPCC
Child #1
Name | Child #1*
First Middle Last
The name of your first child at RPCC
Date of Birth | Child #1*
Date Format: DD slash MM slash YYYY

Their first child's birthday
Child #2
Name | Child #2*
First Middle Last
The name of your second child at RPCC
Date of Birth | Child #2*
Date Format: DD slash MM slash YYYY

Their second child's birthday
Child #3
Name | Child #3
First Middle Last
The name of your third child at RPCC
Date of Birth | Child #3*
Date Format: DD slash MM slash YYYY

Their third child's birthday
Child #4
Name | Child #4*
First Middle Last
The name of your fourth child at RPCC
Date of Birth | Child #4*
Date Format: DD slash MM slash YYYY

Their fourth child's birthday
Parent/Guardian Details
Parent/Guardian #1*
Parent/guardian one's name
Relationship to child*
Relationship to child details*
Phone number*
Enter the best number to reach you on
Email

Enter your email address
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Enter parent/guardian #1's address
Parent/Guardian #2*
Parent/guardian two's name
Relationship to child*
Relationship to child details*
Phone number*
Enter the best number to reach you on
Email

Enter your email address
Address (if different to guardian #1)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Enter parent/guardian #2's address
Emergency Contact Details
Emergency Contact #1*
First Last
Enter the name of your first emergency contact
Relationship to child*
Telephone #1*
Optional | Telephone #2
Emergency Contact #2*
First Last
Enter the name of your second emergency contact
Relationship to child*
Telephone #1*
Optional | Telephone #2
Add another emergency contact?*
- Yes
- No
Emergency Contact #3*
First Last
Relationship to child*
Telephone #1*
Optional | Telephone #2
Add another emergency contact*
- Yes
- No
Emergency Contact #4*
First Last
Relationship to child*
Telephone #1*
Telephone #2
Your child's health
IS YOUR CHILD IMMUNISATION UP TO DATE?*
- YES
- NO
Signed*
ENTER YOUR NAME TO CONFIRM THAT THE DETAILS ABOVE ARE CORRECT. OR PLEASE BRING IN YOUR BLUE BOOK FOR US TO PHOTOCOPY.
HAVE THERE BEEN ANY NEW ALLERGIES OR HEALTH CONCERNS THAT WE NEED TO KNOW ABOUT?*
- Yes
- No
PLEASE CONTACT US STRAIGHT AWAY IF THERE ARE.
Phone
This field is for validation purposes and should be left unchanged.

CONFIDENTIAL

MEDICATION INSTRUCTION

TIME

AUTHORISATION AND RELEASE