After School Centre Step 1 of 9 11% Please fill in the form below to secure a place for your child at an After School Centre in 2018.What would you like to do?*Enrol new studentRe-enrol student Please enter your child's details below.Surname*Given Names*Hebrew NameGender*MaleFemaleHome Address*Suburb*Postcode*School (2018)*Grade (2018)*School (2017)*Hebrew Level (New Students Only)BeginnerIntermediateAdvancedSpeaks/UnderstandsDate of Birth* What is the main language spoken at home?What is the cultural and religious background of your child/children?Would you like to add another child to this enrolment?*YesNoSecond ChildSurname*Given Names*Hebrew NameGender*MaleFemaleHome Address*Suburb*Postcode*School (2018)*Grade (2018)*School (2017)*Hebrew Level (New Students Only)*BeginnerIntermediateAdvancedSpeaks/UnderstandsDate of Birth* Would you like to add another child to this enrolment*YesNoThird ChildSurname*Given Names*Hebrew NameGender*MaleFemaleHome Address*Suburb*Postcode*School (2018)*Grade (2018)*School (2017)*Hebrew Level (New Students Only)BeginnerIntermediateAdvancedSpeaks/UnderstandsDate of Birth* Would you like to add another child to this enrolment?*YesNoFourth ChildSurname*Given Names*Hebrew NameGender*MaleFemaleHome Address*Suburb*Postcode*School (2018)*Grade (2018)*School (2017)*Hebrew Level (New Students Only)BeginnerIntermediateAdvancedSpeaks/UnderstandsDate of Birth* For Childcare Benefits at Merkaz Bentleigh OnlyCRN for Registered ParentDate of Birth of Registered Parent CRN for ChildDate of Birth of Child Second Child CRN DetailsCRN for Second ChildDate of Birth of Second Child Third Child CRN DetailsCRN for Third ChildDate of Birth of Third Child Fourth Child CRN DetailsCRN for Fourth ChildDate of Birth of Fourth Child MEDICAL AND SPECIAL NEEDS DETAILSDoctor's Name*Doctor's Phone*Doctor's Address*Medicare Number*Is your child taking permanent medications?*YesNoIf yes, what is their name?The centre has consent to give medical attention and ambulance if needed?*YesNoThe centre has consent for excursions?*YesNoPlease specify all medication being taken by your child*Does your child have any dietary restrictions?*YesNoIf yes, which child?Please specify your child's dietary restrictions*Does your child have any known allergies (incl. reactions to medications) and any present medical conditions?*YesNoIf yes, which child?Please specify your child's allergies and/or medical conditions*Please attach documentation (Anaphylaxis / Nut Allergy / Allergic Reactions / Asthma / Other - Management Plan)Is there anything else you would like us to know about your child?*YesNoWhat is the cultural and religious background of your child/children?**Please tell us more about your child* PARENTS DETAILSRelationship*MotherFatherSurname*Given Names*Home Address*Home PhoneWork PhoneMobile*Email* Are there any court orders or parenting orders in place for access to the child?*YesNoPlease give details of custody agreements*Please attach legal documentation for custody agreement*Family Email (All communications will be via email)*Both ParentsMotherFatherWould you like to add another parent's details?*YesNoSecond Parent's DetailsSurname*Given Names*Home Address*Home PhoneWork PhoneMobile*Email* Emergency ContactIs there another person you would like to give consent for pick up?*YesNoNameContact Phone Number EMERGENCY CONTACT (OTHER THAN PARENTS)Name*Home PhoneMobile Phone*Relationship to Child*AddressAuthorised to authorise to collect child?*YesNoAuthorised to give consent for medical attention?*YesNoAuthorised to give consent for ambulance?*YesNoWould you like to enter another emergency contact?*YesNoSecond Emergency ContactName*Home PhoneMobile Phone*Relationship to child*AddressAuthorised to authorise consent to collect child?*YesNoAuthorised to authorise consent for medical attention*YesNoAuthorised to authorise consent for ambulance?*YesNo GENERAL INFORMATIONUntitled I authorise my phone number and email address to be published in a class list I can assist UJEB by ocassional volunteering If needed, my business can assist UJEB Yes No How can your business assist UJEB?*How did you find out about UJEB. Please specify ENROLMENT DETAILSMerkaz Bentleigh Mon (Hebrew Only) Tues Wed Caulfield Junior College - Tuesday Jewish studies and Hebrew (until 5:30pm) Jewish studies only (until 5pm) Information required on UJEB Camp UJEB Bat Mitzvah Program UJEB HIGH at high schools Bar or Bat Mitzvah program I give permission for my child's photo to be used for marketing purposes please tick for authorisation PAYMENT DETAILS Person responsible for paymentName*Mobile*Email*Payments are made by credit card. One of the following options must be ticked* Please debit my credit card on the Friday prior to commencement of the school term or on the closest business day if Friday falls on a Jewish/Civil holiday. (A member of the UJEB team will contact you to get your credit card details) I would like to discuss a payment plan / fee remission / application for scholarship CONDITIONS OF ENROLMENT - UJEB AFTER SCHOOL HEBREW CENTRE PROGRAMS I understand and accept the cost of the program and agree to pay in full at the beginning of each term unless alternate arrangements are made with UJEB. I understand that enrolment is not final until a completed enrolment form is received and payment plan is accepted. I commit to inform the office of any changes to my credit card details. I understand that withdrawal of my child must be given in writing prior to the date payment for the next term is due. I acknowledge that no refunds will be issued after this date. UJEB reserves all rights permitted by law to refuse enrolment to any student. UJEB reserves the right to dismiss any student deemed to behave inappropriately. Parents of any such students will not be entitled to any refund whatsoever of any payments made to UJEB in the course of their child’s studies. I understand that UJEB and its employees and volunteers will exercise the ordinary standard of care as required by law. I also understand that UJEB nor any of its employees or volunteers accepts any liability whatsoever for any accident or injury concerning my child while in their care which occur for reasons other than a breach of the ordinary standard of care and indemnify them against any claim which may arise. All information contained in this form is true and correct. I understand that some information in this form may be relied upon by UJEB in certain circumstances including but not limited to medical emergencies and will not hold UJEB responsible for any consequences arising from any false or misleading information I have given. I understand that my child will be given food and drink throughout the year as part of the curriculum and have advised of all relevant allergies and dietary requirements in this form. I give UJEB or any employee or volunteer of UJEB full authority to seek reasonable medical attention necessary for my child where circumstances reasonably require them to do so. I agree to bear all costs involved in any medical attention my child receives while s/he is in their care. I have read, understood and agree to be bound by UJEB’s Child Protection Policy as contained on the UJEB website. I understand that photos and/or videos of activities at the centre and functions may be used for UJEB publicity purposes. I have read and agree to be bound by the above conditions of enrolment in their entirety. I understand that in signing below, I am doing so in my capacity as a parent or legal guardian. I understand that my child’s enrolment will not be accepted unless these conditions are signed by a parent or guardian. Untitled This iframe contains the logic required to handle Ajax powered Gravity Forms.