Mochi House Enrolment Form Mochi House Enrolment Form Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 Page 7 Company Child's Details Child's Surname * Child's Given Name(s) * Preferred name Date of Birth * Gender * Male Female Home address * Suburb * State * Postcode * Languages spoken by child * Languages spoken at home Medical History and Information If you answer "yes" to any of the below questions, please provide a Medical Management Plan and/or support letter from your doctor prior to commencement. Does your child have any current health care needs or medical conditions? * Yes No Does your child have any allergies? * Yes No Does your child have any dietary requirements (including cultural/religious requirements)? * Yes No Has your child been diagnosed at risk of anaphylaxis? * Yes No Does your child have a history of illness or injury? * Yes No Has your child been diagnosed with asthma? * Yes No Does your child have any particular learning, development or behavioural challenges? * Yes No Is your child toilet trained? * Yes No In progress Comments Anything else you would like to tell us about your child's health: PLEASE READ CAREFULLY BEFORE CHECKING THIS BOX: In consenting to my child's participation in Mochi House I understand the risks and hazards to which my child may be exposed while receiving care, and will not hold Mochi Music accountable for any loss or injury that the child sustains. * Yes, I understand Parent/Guardian 1 Details Parent's Surname * Parent's Given Name(s) * Relationship to child * Languages spoken * Is home address same as child's? Yes No Mobile number * Home phone Email address * Authorised to collect child? * Yes No Parent/Guardian 2 Details Parent's Surname Parent's Given Name(s) Relationship to child Languages spoken Is home address same as the child's? Yes No Mobile number Home phone Email address Authorised to collect child? Yes No Emergency Contact Emergency Contact Full Name * Relationship to child * Street Address * Suburb * State * Postcode * Mobile Phone * Home Phone Work Phone I give permission for the above emergency contact to: * Collect the child from Mochi Music. Authorise medical treatment of, or administration of medication to the child. Authorise on my behalf an authorised educator to take the child outside the education and care service premises. Would you like to add another emergency contact? * Yes No Medical Service Doctor's Full Name Medical Practice Phone number Email Street Address Suburb State Postcode Dentist Full name Dental Practice Phone number Email Street Address Suburb State Postcode About My Child Are there any words that we may need to know that have a special meaning? What experience does your child have in being cared for by other people outside your immediate family (e.g extended family, other child care centre, nanny, etc): Tell us about your child - (This could include their routine, interests, likes, dislikes, food requirements, and sleep patterns) What are your goals for your child at Mochi House? Please let us know anything else that you feel may assist us in providing the best experience for your child: Do you give permission for photographs and video of your child to be featured on the Mochi Music website and associated social media sites? * Yes No
