APPLICATION FORM

Any changes to the original enrolment agreement form must be signed and dated by the parent/guardian.

Please write clearly. All the information on this form is important and must be filled in properly. Privacy Statement: All the information on your child will be kept securely and remain confidential. Any changes to this form must be signed and dated by the parent/guardian

A false declaration may be an offence and you may be liable for prosecution

Child :
Child’s official Full Name*
FirstLast
Name your child is known by / preferred name:*
FirstLast
Copy of official identity verification document* collected by staff:*
- New Zealand birth certificate
- New Zealand passport
- Foreign birth certificate
- Foreign passport
- Other
- Staff initials
Other
Staff Initials
Child Date of Birth*
Gender*
- Male
- Female
Ethnic origin:
Iwi your child belongs to:
Language/s spoken at home:
Privacy Statement:
- We are collecting personal information on this enrolment form for the purposes 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 you or 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 more information about national student numbers at: www.minedu.govt.nz/parents
- * Information about acceptable identity verification documents is available online at
- www.lead.ece.govt.nz and www.minedu.govt.nz/parents.
  The Ministry recommends that all services keep a copy of the identity verification document of each child who is enrolled at the service.
- Privacy Statement:
  All personal information on your child will be kept securely and remain confidential.
- Any changes to this form must be signed and dated by the parent/guardian.

Parents / Guardians:
Name*
FirstLast
Address*
Street AddressAddress Line 2CityState / Province / RegionZIP / Postal CodeCountry
Phone (Home/Work):*
Phone(Mobile)*
Email*
Additional person/s who can pick up your child:*
Street AddressAddress Line 2CityState / Province / RegionZIP / Postal CodeCountry
Custodial Statement
Are there any custodial arrangements concerning your child?
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
Name
FirstLast
Name
FirstLast
Privacy Statement:
- Privacy Statement:
  All personal information on your child will be kept securely and remain confidential.
- Any changes to this form must be signed and dated by the parent/guardian.

Emergency Contacts:
Name*
FirstLast
Phone*
Email*
Address
Street AddressCityZIP / Postal Code
Name
FirstLast
Phone
Email*
Address
Street AddressCityZIP / Postal Code
Child’s doctor
Name*
FirstLast
Phone*
Address
Street AddressCityZIP / Postal Code
Privacy Statement:
- Privacy Statement:
  All personal information on your child will be kept securely and remain confidential.
- Any changes to this form must be signed and dated by the parent/guardian.

Enrolment 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. Little Feet Childcare Centre optional charges will apply to extra services.
Day & Time Enrollement
Monday
Tuesday
Wednesday
Thursday
Friday
For 20 Hours ECE fill out boxes below with the hours attested e.g. 6 hours
20 Hours ECE at this service
Monday
Tuesday
Wednesday
Thursday
Friday
20 Hours ECE at another service
Monday
Tuesday
Wednesday
Thursday
Friday
Parents/Guardian Signature*
Date*
Privacy Statement:
- Privacy Statement:
  All personal information on your child will be kept securely and remain confidential.
- Any changes to this form must be signed and dated by the parent/guardian.

20 Hours ECE Attestation:
1. Is your child receiving 20 Hours ECE for up to six hours per day, 20 hours per week at this service?
- Yes
- No
2. Is your child receiving 20 Hours ECE at any other services?
- Yes
- No
If yes to either or both of the above, please sign to confirm that:
- 1.Your child does not receive more than 20 hours of 20 Hours ECE per week across all services.
- 2.Your 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.
- 3.You consent to the early childhood education 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.
Parents/Guardian Signature*
Date*
Optional Charges:
- If you request Optional Charges, this agreement must be included as part of your service’s Enrolment Agreement Form
- a) Concerts and or parents day
- b) Meals
- c) Extra enrolment hours apart from the allocated government funding hours
- d) Extra teachers
- e) Trips
- 2. I understand that if I agree to pay for the optional charge, Little Feet Childcare Centre may enforce payment.
- 3. The agreement to pay the optional charge will last for as long as the child is enrolled in the centre
- 4. The rules about making changes to the agreement are:
- a) Written notice within 2 weeks of acceptance of enrolment
- 5. I understand that optional charge is not compulsory and if I choose not to pay there will be no penalty but extra services will be charged for at cost.
- I agree/do not agree (select one) to pay the optional charge for the activities/items specified in this enrolment agreement form
Parents/Guardian Signature*
Date*
Privacy Statement:
- Privacy Statement:
  All personal information on your child will be kept securely and remain confidential.
- Any changes to this form must be signed and dated by the parent/guardian.

APPLICATION FORM

Application Form

Step 1 of 7

Child :

Privacy Statement:

The Ministry recommends that all services keep a copy of the identity verification document of each child who is enrolled at the service.

Privacy Statement:

Parents / Guardians:

Custodial Statement

Person/s who cannot pick up your child

Privacy Statement:

Privacy Statement:

Emergency Contacts:

Child’s doctor

Privacy Statement:

Privacy Statement:

Enrolment Details:

Please Note:

Day & Time Enrollement

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

20 Hours ECE at this service

20 Hours ECE at another service

Privacy Statement:

Privacy Statement:

20 Hours ECE Attestation:

If yes to either or both of the above, please sign to confirm that:

Optional Charges:

Privacy Statement:

Privacy Statement:

Statutory Holidays / Term Breaks

Dual Enrolment Declaration

If paying by automatic payment, please enter the following details on your bank account:

Health

Medicine

Category (i) Medicines

Category (ii) Medicines

Category (iii) Medicines

Privacy Statement:

Privacy Statement:

Parent Declaration

Service Declaration

Change of Days/Times of Enrolment:

Day & Time Enrolled

For 20 Hours ECE fill out boxes below

20 Hours ECE at this service

20 Hours ECE at another service

Privacy Statement:

Privacy Statement: