Registration - Little Poppins

FAMILY REGISTRATION FORM

Name

We request that all items marked with * please be completed

Street address *

Suburb *

Post code *

Parent/Guardian Contact details

Parent/guardian 1 (Primary Contact)*

Name *

Email Address *

Occupation

Preferred phone number :

Mobile phone number *

Home phone number

Work place and phone number

Parent/Guardian 2 (Emergency Contact)

Name

Email Address

Occupation

Preferred phone number :

Mobile phone number

Home phone number

Work place and phone number

Children’s details

Number of Children*

1. Name *

Gender *

Age *

Date of Birth * ×

School/Kindy attending

Year/Grade

Toilet Training

Interests

2. Name *

Gender *

Age *

Date of Birth * ×

School/Kindy attending

Year/Grade

Toilet Training

Interests

3. Name *

Gender *

Age *

Date of Birth * ×

School/Kindy attending

Year/Grade

Toilet Training

Interests

4. Name *

Gender *

Age *

Date of Birth * ×

School/Kindy attending

Year/Grade

Toilet Training

Interests

5. Name *

Gender *

Age *

Date of Birth * ×

School/Kindy attending

Year/Grade

Toilet Training

Interests

Emergency Contacts (other than parents)

Contact 1

Name *

Contact Number *

Relationship to Child *

Contact 2 (optional)

Name

Contact Number

Relationship to Child

General Household Information

Pets

Stairs

Swimming Pool *

Other Potential Hazards/Household Information

Medical Information

Immunisations :

Is each child up to date with his/her immunisations?

Yes

No

If yes, please provide details of each child’s most recent Immunisations (ie. 6 month Immunisations)

Write here

Allergies * :

Do any of your children have any allergies? **

Yes

No

If yes, please describe what treatment is required (or potentially required) while the child(ren) is/are in care of a Little Poppins Nanny. **

Write here

Dietary Requirements * :

Do any of your children have any special dietary requirements we need to be aware of? **

Yes

No

If yes, please provide details. *

Write here

Medical Conditions * :

Does your child have any ongoing medical conditions and if so do they require ongoing medication?
e.g. Asthma, Diabetes, Cystic Fibrosis **

Yes

No

If yes, please provide details below and please complete the attached medication authorization form each time you leave your child in care of a Little Poppins Nanny.*

Write here

Medical Consents * :

In case of emergency, or if we are unable to contact either parent or emergency contact, Little Poppins Nanny will seek medical treatment deemed necessary (First Aid, medical, dental, ambulance, hospital) for your child, and that you accept full liability and any costs incurred for such medical treatment? **

Yes

No

Details of Booking

Type of Service :*

Babysitter

Mother’s Helper

Casual/Short-Term Nanny

Ongoing Nanny

Commencing:

Date ×

Start Time

Finish Time

Date ×

Start Time

Finish Time

Date ×

Start Time

Finish Time

Candidate Preferences :

Age range :

Other specifics (eg. Nanny you have used previously) :

3 key requirements you are looking for in a candidate :

1.

2.

3.

Will the Nanny be required to drive the child(ren)?

Yes

No

Will the Nanny need her own car for transporting children?

Yes

No

Ongoing Placement Requirement

Placement start date : ×

Placement end date : ×

Monday Start

Tuesday Start

Wednesday Start

Thursday Start

Friday Start

Saturday Start

Sunday Start

Monday Finish

Tuesday Finish

Wednesday Finish

Thursday Finish

Friday Finish

Saturday Finish

Sunday Finish

Feedback

(There is no obligation to complete this section, however your feedback is important to us.) How did you hear about Little Poppins?

Advertising

Facebook

Internet Search

Word of Mouth

Please let us know who referred you so we can thank them appropriately :

LITTLE POPPINS

General Consents and Acknowledgments :

(Note: all references to “Nanny” below also include references to Little Poppins’ babysitters and mother’s helpers)

I / We consent to the Little Poppins Nanny applying sun cream (as per requirements of the Cancer Council of SA) to my child prior to them participating in outdoor play.

I / We understand and accept that if the Nanny is able to leave the house with my/our child(ren) on any specific occasion I/we will complete the attached Authorisation for Excursion/Driving form on each occasion (as required).

I / We understand and accept that if the Nanny is required to administer medication to my/our child(ren) n any specific occasion I/we will complete the attached Authority to Administer Medication form.

I/We understand and accept that the environment will be free of tobacco smoke while children are in the care of a Little Poppins Nanny.

I/We understand and accept that First Aid provisions must be accessible to the Nanny in the home.

I/We understand that it is illegal to film a Nanny in our home without her consent.

I/We understand and accept the Little Poppins Fee Structure and that Fees are to be kept up to date.

I/We understand and accept that under no circumstances should payment be made to the Nanny directly, but should be made through Little Poppins.

I/We understand and accept that I/we am/are not permitted to disclose the Nanny’s contact details to other parties with a view to them engaging the Nanny, but use of the Nanny by other parties is only to be arranged through Little Poppins.

I/We understand and accept that any costs incurred in the collection of outstanding accounts (either Mercantile Agency fees or legal fees) will be my responsibility.

*Signed

(Electronic (typed) signature is acceptable)

Parent/Guardian 1 Signature*

Type your signature here

Date : ×

And/Or

Parent/Guardian 2 Signature

Type your signature here

Date : ×

FAMILY REGISTRATION FORM

We request that all items marked with * please be completed

Parent/Guardian Contact details

Parent/guardian 1 (Primary Contact)*

Preferred phone number :

Parent/Guardian 2 (Emergency Contact)

Preferred phone number :

Children’s details

Emergency Contacts (other than parents)

Contact 1

Contact 2 (optional)

General Household Information

Medical Information

Immunisations :

Allergies * :

Dietary Requirements * :

Medical Conditions * :

Medical Consents * :

Details of Booking

Commencing:

Candidate Preferences :

3 key requirements you are looking for in a candidate :

Ongoing Placement Requirement

Feedback

(There is no obligation to complete this section, however your feedback is important to us.) How did you hear about Little Poppins?

LITTLE POPPINS

General Consents and Acknowledgments :

(Note: all references to “Nanny” below also include references to Little Poppins’ babysitters and mother’s helpers)

I / We consent to the Little Poppins Nanny applying sun cream (as per requirements of the Cancer Council of SA) to my child prior to them participating in outdoor play.

I / We understand and accept that if the Nanny is able to leave the house with my/our child(ren) on any specific occasion I/we will complete the attached Authorisation for Excursion/Driving form on each occasion (as required).

I / We understand and accept that if the Nanny is required to administer medication to my/our child(ren) n any specific occasion I/we will complete the attached Authority to Administer Medication form.

I/We understand and accept that the environment will be free of tobacco smoke while children are in the care of a Little Poppins Nanny.

I/We understand and accept that First Aid provisions must be accessible to the Nanny in the home.

I/We understand that it is illegal to film a Nanny in our home without her consent.

I/We understand that it is illegal to film a Nanny in our home without her consent.

I/We understand and accept the Little Poppins Fee Structure and that Fees are to be kept up to date.

I/We understand and accept that under no circumstances should payment be made to the Nanny directly, but should be made through Little Poppins.

I/We understand and accept that I/we am/are not permitted to disclose the Nanny’s contact details to other parties with a view to them engaging the Nanny, but use of the Nanny by other parties is only to be arranged through Little Poppins.

I/We understand and accept that any costs incurred in the collection of outstanding accounts (either Mercantile Agency fees or legal fees) will be my responsibility.

*Signed

(Electronic (typed) signature is acceptable)

And/Or

Your form has been submitted

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