Modified diet care plan

Modified diet care plan
CONFIDENTIAL

To be completed by the DOCTOR OR DIETITIAN and the PARENT/GUARDIAN.
This form is to be used where a child has a proven history of food allergy or intolerance or requires a special diet for a proven medical condition.
This information is confidential and will be available only to supervising staff and emergency medical personnel.
Name of child

(Family name) (First name)
Date of birth
MM slash DD slash YYYY
MedicAlert Number (if relevant)
Review date
MM slash DD slash YYYY
Description of special dietary or fluid needs.
Foods and substances that must be avoided.
Alternative foods the person can consume
(eg soy products instead of standard dairy for lactose intolerance).
Details of any special feeding routine
(eg meals at particular times or intervals for health reasons).
In the case of food allergy/intolerance, what are the signs and symptoms?
Please indicate whether the person can report symptoms, the time period over which symptoms might emerge and the severity of the anticipated reaction.
First aid response to signs and symptoms of an allergic reaction/intolerance to a food or other substance.
Please complete the first aid action plan on the back of this form. If the reaction is severe, an anaphylaxis care plan, including an emergency first aid response, will be required from the treating medical practitioner.
This plan has been developed for the following services : Long Day Care
AUTHORISATION AND RELEASE
Health professional
Professional role
Address
Telephone
Signature*
Date
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

(Family name)(First name)
Signature*
Date
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*
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*
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*
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...*
DD dash MM dash YYYY
For...
Amount of weeks..
...or until
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*
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*
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*
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*
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

This plan has been developed for the following services : Long Day Care

AUTHORISATION AND RELEASE