Administration Records Enrolment Agreement Form [INSERT NAME OF
SERVICE]
A SAMPLE THAT COVERS THE NECESSARY FUNDING AND LICENSING
REQUIREMENTS
Enrolment Information, 20 Hours ECE Enrolment hours and Attestation Information for Earl Childhood
Edu!ation Ser"i!es
An !hanges to the original enrolment agreement form must #e signed and dated # the $arent%guardian&
Se!tions mar'ed (ith this sm#ol are re)uired to #e in!luded in e"er Enrolment Agreement Form *+, -ours
ECE se!tions are not a$$li!a#le if the ser"i!e does not offer +, -ours ECE.&
/ording !annot #e !hanged, e0!e$t to add rele"ant details for our ser"i!e&
Chi!"
Child1s first names2 Surname2
Name our !hild is 'no(n #2
Child1s date of #irth2 Male Female
Ethni! origin2
I(i our !hild #elongs to2
Child1s home address or addresses2
3ost!ode
P#r$%ts & Gu#r!i#%s"
First Names2 First Names2
Surname2 Surname2
Address2 Address2
3ost Code2 3ost Code2
3hone *-ome.2 3hone *-ome.2
3hone */or'.2 3hone */or'.2
3hone *Mo#ile.2 3hone *Mo#ile.2
Email2 Email2
First Names2 First Names2
Surname2 Surname2
Address2 Address2
3ost Code2 3ost Code2
3hone *-ome.2 3hone *-ome.2
3hone */or'.2 3hone */or'.2
3hone *Mo#ile.2 3hone *Mo#ile.2
Email2 Email2
Privacy Statement: All $ersonal information on our !hild (ill #e 'e$t se!urel and remain !onfidential&
An !hanges to this form must #e signed and dated # the $arent%guardian&
3age 4 of 5
Em$r'$%() Co%t#(ts"
First Names2 First Names2
Surname2 Surname2
Address2 Address2
3ost Code2 3ost Code2
3hone *-ome.2 3hone *-ome.2
3hone */or'.2 3hone */or'.2
3hone *Mo#ile.2 3hone *Mo#ile.2
Email2 Email2
First Names2
Surname2
Address2
3ost Code2
3hone *-ome.2
3hone */or'.2
3hone *Mo#ile.2
Email2
Do(tor"
Name2 3hone2
Address2
E%rom$%t D$t#is"
6ate of Enrolment27777 %7777 % 777 6ate of Entr2 7777 %7777 % 7777 6ate of E0it2 7777 %7777 % 7777
P$#s$ Not$" +, -ours ECE is for u$ to si* hours +$r !#), u$ to 20 hours +$r ,$$- and there must .$ %o
!om$ulsor fees (hen a !hild is re!ei"ing +, -ours ECE funding&
6as Enrolled2 Monda Tuesda /ednesda Thursda Frida
Times Enrolled2 Total num#er
of hours2
For 20 Hours ECE /i out .o*$s .$o, ,ith th$ hours #tt$st$! $0'0 1 hours
+, -ours ECE at this
ser"i!e
Total num#er
of hours2
+, -ours ECE at
another ser"i!e
Total num#er
of hours2
3arent%8uardian Signature2 7777777777777777777777777777 6ate2 7777 %7777 % 7777
Privacy Statement: All $ersonal information on our !hild (ill #e 'e$t se!urel and remain !onfidential&
An !hanges to this form must #e signed and dated # the $arent%guardian&
3age + of 5
20 Hours ECE Att$st#tio%"
4& Is our !hild re!ei"ing +, -ours ECE for u$ to si0 hours $er da, +, hours $er (ee' at this ser"i!e9
Tick One :es No
2. Is our !hild re!ei"ing +, -ours ECE at an other ser"i!es9 Tick One :es No
If es to either or #oth of the a#o"e, $lease sign to !onfirm that2
:our !hild does not re!ei"e more than +, hours of +, -ours ECE $er (ee' a!ross all ser"i!es&
:our authorise the Ministr of Edu!ation to ma'e en)uiries regarding the information $ro"ided in the
Enrolment Agreement Form, if deemed ne!essar and to the e0tent ne!essar to ma'e de!isions a#out
our !hild1s eligi#ilit for +, -ours ECE.
:ou !onsent to the earl !hildhood edu!ation ser"i!e $ro"iding rele"ant information to the Ministr of
Edu!ation, and to other earl !hildhood edu!ation ser"i!es our !hild is enrolled at, a#out the
information !ontained in this #o0&
3arent%8uardian Signature2 77777777777777777777777777777 6ate2 7777 %7777 % 7777
O+tio%# Ch#r'$s"
If you request Optional Charges, this agreement must be included as part of your services Enrolment
greement !orm
!or further information on Optional Charges please refer to Chapter " of the Early Childhood Education
!unding #andbook
4& The o$tional !harge is for2 *$lease gi"e details of s$e!ifi! a!ti"ities or items.
+& I understand that if I agree to $a for the o$tional !harge, [insert name of ser"i!e] ma enfor!e $ament&
;& The agreement to $a the o$tional !harge (ill last for2 [insert time]
<& The rules a#out ma'ing !hanges to the agreement are2 *ou must gi"e the $arent a reasona#le o$$ortunit
in (hi!h to !hange their mind.2
*3lease insert rules here.
=& I understand that that o$tional !harge is not !om$ulsor and if I !hoose not to $a there (ill #e no
$enalt&
6. I agree%do not agree $select one% to $a the o$tional !harge for the a!ti"ities%items s$e!ified in this
enrolment agreement form
3arent%8uardian Signature2 77777777777777777777777777777 6ate2 7777 %7777 % 7777
Privacy Statement: All $ersonal information on our !hild (ill #e 'e$t se!urel and remain !onfidential&
An !hanges to this form must #e signed and dated # the $arent%guardian&
3age ; of 5
St#tutor) Hoi!#)s & T$rm 2r$#-s
This enrolment agreement is [in!lusi"e%e0!lusi"e ] of s!hool term #rea's&
If our ser"i!e is o$en on Statutor -olidas, $arents need to !onfirm enrolment for ea!h indi"idual statutor
holida& Not$" 3lease inform us of an alteration in hours&
[insert name of ser"i!e] is o$en on the follo(ing $u#li! holidas if the fall on a (ee'da& 3lease ti!' the das
ou (ish our !hild to #e s$e!ifi!all enrolled for2
New Years Day Easter Monday Christmas Day
Day after New Years Day ANZAC Day Boxing Day
Waitangi Day Queen's Birthday Loa! Anni"ersary Day
#ood $riday La%our Day
Du# E%rom$%t D$(#r#tio%
I here# de!lare that m !hild is not enrolled at another earl !hildhood institution at the same times that he%she
is enrolled at2 [insert name of ser"i!e]
3arent%8uardian Signature2 77777777777777777777777777777 6ate2 7777 %7777 % 7777
Hom$32#s$! E!u(#tio% #%! C#r$ S$r4i($s O%)
This s$(tio% is # (om+usor) r$5uir$m$%t /or E%rom$%t A'r$$m$%t Forms us$! .) Hom$32#s$!
S$r4i($s
Is the edu!ator (ho (ill #e $ro"iding edu!ation and !are for our !hild a mem#er of the !hild1s famil9
Tick One :es No
If es, (hat is the relationshi$ of the edu!ators to our !hild9
3arent%8uardian Signature2 77777777777777777777777777777 6ate2 7777 %7777 % 7777
Custo!i# St#t$m$%t
Are there an !ustodial arrangements !on!erning our !hild9
If YES, $lease gi"e details of an !ustodial arrangements or !ourt orders *a !o$ of an !ourt order is re)uired.
P$rso%&s ,ho (#%%ot +i(- u+ )our (hi!2
Name2 Name2
Name2 Name2
Privacy Statement: All $ersonal information on our !hild (ill #e 'e$t se!urel and remain !onfidential&
An !hanges to this form must #e signed and dated # the $arent%guardian&
3age < of 5
P$rso%&s ,ho (#% +i(- u+ )our (hi!"
First Names2 First Names2
Surname2 Surname2
Address2 Address2
3ost Code2 3ost Code2
3hone *-ome.2 3hone *-ome.2
3hone */or'.2 3hone */or'.2
First Names2 First Names2
Surname2 Surname2
Address2 Address2
3ost Code2 3ost Code2
3hone *-ome.2 3hone *-ome.2
3hone */or'.2 3hone */or'.2
3hone *Mo#ile.2 3hone *Mo#ile.2
H$#th
Illness%allergies2
Is our !hild u$>to>date (ith immunisations9 Tick One :es No
*3lease $ro"ide "erifi!ations of all immunisations.
Immunisations re!ord sighted and details re!orded2 Tick One :es No
M$!i(i%$
C#t$'or) 6i7 M$!i(i%$s
A !ategor *i. medi!ine is a non>$res!ri$tion $re$aration *su!h as arni!a !ream, antise$ti! li)uid, inse!t #ite
treatment. that is not ingested, used for the ?first aid1 treatment of minor in@uries and $ro"ided # the ser"i!e and
'e$t in the first aid !a#inet&
Note2 The ser"i!e must $ro"ide s$e!ifi! information a#out the !ategor *i. $re$arations that (ill #e used
6o ou a$$ro"e !ategor *i. medi!ines to #e used on our !hild9 Tick One :es No
Name%s of s$e!ifi! !ategor *i. medi!ines that !an #e used on m !hild, +ro4i!$! .) s$r4i($2
3arent%8uardian Signature2 77777777777777777777777777777 6ate2 7777 %7777 % 7777
Privacy Statement: All $ersonal information on our !hild (ill #e 'e$t se!urel and remain !onfidential&
An !hanges to this form must #e signed and dated # the $arent%guardian&
3age = of 5
C#t$'or) 6iii7 M$!i(i%$s
To #e filled in if our !hild re)uires medi!ation as $art of an indi"idual health $lan, for e0am$le for an on>going
!ondition su!h as asthma or e!Aema et! and is for the use of that !hild onl
Indi"idual health $lan !om$leted and signed2 Tick One :es No
Name of medi!ine2
Method and dose of medi!ine2
/hen does the medi!ine need to #e ta'en2 *State time or s$e!ifi! sm$toms.
3arent%8uardian Signature2 77777777777777777777777777777 6ate2 7777 %7777 % 7777
R$5uir$! I%/orm#tio% /or Li($%si%' Pur+os$s
E0!ursions2
3ermission for the !hild to ta'e $art in regular e0!ursions *under the !onditions stated in the e0!ursions
$oli!.
3hoto%"ideo2 $ermission for the !hild to #e $hotogra$hed for the $ur$oses of assessment, $lanning and
e"aluation *e0$lain !learl ho( the $hoto1s%"ideos !an%!an1t #e used.
Oth$r i%/orm#tio% +ossi.$ to i%(u!$ o% this E%rom$%t A'r$$m$%t Form
Poi() St#t$m$%t" [insert name of ser"i!e] has a num#er of $oli!ies that set out the $ro!edures that are in
$la!e for the !are and edu!ation of the !hildren (ho attend& /e strongl urge ou to read these& The
signing of this enrolment agreement form indi!ates that ou (ill a#ide # the $oli!ies of this ser"i!e, and
understand ho( ou !an ha"e in$ut to $oli! re"ie(&
P#r$%t I%/orm#tio% 2oo-2 3lease ensure ou ha"e read the information in the $arent hand#oo' as it
!o"ers su!h things as fee details, su#sidies that are a"aila#le to ou and (as in (hi!h (e !an hel$ ou
and our !hild settle into the ser"i!e&
Pri4#() St#t$m$%t" All $ersonal information on our !hild (ill #e 'e$t se!urel and remain !onfidential&
Chi!8s str$%'ths9 i%t$r$sts #%! +r$/$r$%($s" 3lease tell us a#out our !hild1s strengths, interests and
$referen!es
Tr#%sitio%# S(hoo Visits" Information on transition arrangements
Corr$s+o%!$%($ S(hoo E%rom$%t" 6etails of enrolment agreement
P#r$%t D$(#r#tio%
I de!lare that all the a#o"e information is true and !orre!t to the #est of m 'no(ledge
3arent%8uardian Signature2 77777777777777777777777777777 6ate2 7777 %7777 % 7777
S$r4i($ D$(#r#tio%
On #ehalf of [insert name of ser"i!e], I de!lare that this form has #een !he!'ed and all rele"ant se!tions ha"e
#een !om$leted&
Privacy Statement: All $ersonal information on our !hild (ill #e 'e$t se!urel and remain !onfidential&
An !hanges to this form must #e signed and dated # the $arent%guardian&
3age B of 5
Ser"i!e 3ro"ider Signature2 77777777777777777777777777777
6ate2 7777 %7777 % 7777
Privacy Statement: All $ersonal information on our !hild (ill #e 'e$t se!urel and remain !onfidential&
An !hanges to this form must #e signed and dated # the $arent%guardian&
3age C of 5
Ch#%'$ o/ D#)s&Tim$s o/ E%rom$%t"
E//$(ti4$ D#t$ o/ Ch#%'$" 7777 %7777 % 7777
6as Enrolled2 Monda Tuesda /ednesda Thursda Frida
Times Enrolled2 Total
For 20 Hours ECE /i out .o*$s .$o,
+, -ours ECE at this
ser"i!e
+, -ours ECE at another
ser"i!e
3arent%8uardian Signature2 77777777777777777777777777777 6ate2 7777 %7777 % 7777
Ch#%'$ o/ D#)s&Tim$s o/ E%rom$%t"
E//$(ti4$ D#t$ o/ Ch#%'$" 7777 %7777 % 7777
6as Enrolled2 Monda Tuesda /ednesda Thursda Frida
Times Enrolled2 Total
For 20 Hours ECE /i out .o*$s .$o,
+, -ours ECE at this
ser"i!e
+, -ours ECE at another
ser"i!e
3arent%8uardian Signature2 77777777777777777777777777777 6ate2 7777 %7777 % 7777
Ch#%'$ o/ D#)s&Tim$s o/ E%rom$%t"
E//$(ti4$ D#t$ o/ Ch#%'$" 7777 %7777 % 7777
6as Enrolled2 Monda Tuesda /ednesda Thursda Frida
Times Enrolled2 Total
For 20 Hours ECE /i out .o*$s .$o,
+, -ours ECE at this
ser"i!e
+, -ours ECE at another
ser"i!e
3arent%8uardian Signature2 77777777777777777777777777777 6ate2 7777 %7777 % 7777
Privacy Statement: All $ersonal information on our !hild (ill #e 'e$t se!urel and remain !onfidential&
An !hanges to this form must #e signed and dated # the $arent%guardian&
3age 5 of 5
