School Holiday Program Enrolment Form

Transcription

1 Enrolment Form s Children s Services Communities@Work s Children s Services are focused on building strong relationships around the children in our care to ensure the best possible outcomes for children growing up in our community. Communities@Work s Children s Services provide safe, stimulating environments for the nurture and education of children through child care and education centres, family day care, in-home care, and out of school hours care. We also offer family programs to help families maintain healthy, happy relationships with their children. Communities@Work s Centre of Professional Learning and Education is a Registered Training Organisation (88148) that offers quality professional learning and support for the education and care sector. Our programs are spread right across Canberra, all with a focus on providing the best possible nurture for young hearts and minds. Phone: enrolments@commsatwork.org

2 Parent/Guardians must complete this form. Please complete ALL INFORMATION on BOTH SIDES of this application in BLOCK LETTERS. Children s Details Child 1 Name: Child 2 Name: Child 3 Name: Parent/Guardian 1 Name: Parent/Guardian 2 Name: Name of school your child/ren attends: Priority of assessment Single parent, working Both parents working Aboriginal and Torres Strait Islander family n English speaking background: Child in family which includes a disabled person Income support: Socially isolated: Program Use Only Care Order attached: N/A Medical Action Plan attached: N/A Anaphylaxis Action Plan attached: N/A Inclusion Support Request: N/A Children s Services Enrolment Team Use Only Enrolment received by CSET: Date: Entered on QikKids: Copied: Enrolment Fee: Confirmed: CCMS Enrolled / CCR: Ezidebit: D/Debit C/Card 2

3 Confidential Details, Child One Given Names: Address: Child CRN: Gender: Each child has their own Customer Reference Number (CRN). For more information contact Department of Human Services on Indigenous Origin and Cultural Background (please tick relevant box): Aboriginal Torres Strait Islander Aboriginal and Torres Strait Islander Neither Aboriginal or Torres Strait Islander Cultural Background: Does your child speak a language other than English at home? (if yes please specify below) Court Orders Are there any court orders, parenting orders or parenting plans in relation to the child or access to the child? * Health Does your child have any allergies, intolerances or dietary restrictions, e.g. foods, medicine, grass, sunscreen etc? * Severity: Mild Moderate Severe tes: Current (less than 12 months old) Medical Action Plan attached: (if no please provide a copy) Does your child have any medical conditions? E.g. asthma, diabetes, epilepsy etc. * Severity: Mild Moderate Severe tes: Current (less than 12 months old) Medical Action Plan attached: (if no please provide a copy) Has your child been diagnosed as at risk of anaphylaxis? * Current (less than 12 months old) Anaphylaxis Action Plan attached: (if no please provide a copy) Does your child take any medication? E.g. Ventolin, etc. (If yes please provide details) Has your child been diagnosed or undergoing assessment for any areas which may help us in providing an inclusive environment? E.g. ADHD, autism, Aspergers, behaviour etc. (if yes please provide details) Does your child require inclusion support? Permission for information to be obtained for use by the Inclusion Support Agency (refer Communities@Work website): Does your child suffer from fears or phobias? (if yes please provide details) If your child has a diagnosed disability, is there anything that you do or modify at home? (if yes please provide details) Does your child have a need for additional assistance in any of the following areas? Learning Needs Communication Needs Mobility Needs Interpersonal Needs Other Needs 3

4 Confidential Details, Child Two Given Names: Address: Child CRN: Gender: Each child has their own Customer Reference Number (CRN). For more information contact Department of Human Services on Indigenous Origin and Cultural Background (please tick relevant box): Aboriginal Torres Strait Islander Aboriginal and Torres Strait Islander Neither Aboriginal or Torres Strait Islander Cultural Background: Does your child speak a language other than English at home? (if yes please specify below) Court Orders Are there any court orders, parenting orders or parenting plans in relation to the child or access to the child? * Health Does your child have any allergies, intolerances or dietary restrictions, e.g. foods, medicine, grass, sunscreen etc? * Severity: Mild Moderate Severe tes: Current (less than 12 months old) Medical Action Plan attached: (if no please provide a copy) Does your child have any medical conditions? E.g. asthma, diabetes, epilepsy etc. * Severity: Mild Moderate Severe tes: Current (less than 12 months old) Medical Action Plan attached: (if no please provide a copy) Has your child been diagnosed as at risk of anaphylaxis? * Current (less than 12 months old) Anaphylaxis Action Plan attached: (if no please provide a copy) Does your child take any medication? E.g. Ventolin, etc. (If yes please provide details) Has your child been diagnosed or undergoing assessment for any areas which may help us in providing an inclusive environment? E.g. ADHD, autism, Aspergers, behaviour etc. (if yes please provide details) Does your child require inclusion support? Permission for information to be obtained for use by the Inclusion Support Agency (refer Communities@Work website): Does your child suffer from fears or phobias? (if yes please provide details) If your child has a diagnosed disability, is there anything that you do or modify at home? (if yes please provide details) Does your child have a need for additional assistance in any of the following areas? Learning Needs Communication Needs Mobility Needs Interpersonal Needs Other Needs 4

5 Confidential Details, Child Three Given Names: Address: Child CRN: Gender: Each child has their own Customer Reference Number (CRN). For more information contact Department of Human Services on Indigenous Origin and Cultural Background (please tick relevant box): Aboriginal Torres Strait Islander Aboriginal and Torres Strait Islander Neither Aboriginal or Torres Strait Islander Cultural Background: Does your child speak a language other than English at home? (if yes please specify below) Court Orders Are there any court orders, parenting orders or parenting plans in relation to the child or access to the child? * Health Does your child have any allergies, intolerances or dietary restrictions, e.g. foods, medicine, grass, sunscreen etc? * Severity: Mild Moderate Severe tes: Current (less than 12 months old) Medical Action Plan attached: (if no please provide a copy) Does your child have any medical conditions? E.g. asthma, diabetes, epilepsy etc. * Severity: Mild Moderate Severe tes: Current (less than 12 months old) Medical Action Plan attached: (if no please provide a copy) Has your child been diagnosed as at risk of anaphylaxis? * Current (less than 12 months old) Anaphylaxis Action Plan attached: (if no please provide a copy) Does your child take any medication? E.g. Ventolin, etc. (If yes please provide details) Has your child been diagnosed or undergoing assessment for any areas which may help us in providing an inclusive environment? E.g. ADHD, autism, Aspergers, behaviour etc. (if yes please provide details) Does your child require inclusion support? Permission for information to be obtained for use by the Inclusion Support Agency (refer Communities@Work website): Does your child suffer from fears or phobias? (if yes please provide details) If your child has a diagnosed disability, is there anything that you do or modify at home? (if yes please provide details) Does your child have a need for additional assistance in any of the following areas? Learning Needs Communication Needs Mobility Needs Interpersonal Needs Other Needs 5

6 Parent/Guardian One Details Relationship to child: Mother Father Other Please Specify: Are you eligible to claim Child Care Benefit (CCB) and/or Child Care Rebate (CCR): Are you the parent/guardian who receives CCB through the Department of Human Services: Customer Reference Number (CRN): Address: First Name: Gender: Home Phone: Mobile: Work Phone: Work Status: Working Looking for work Studying/Training Disability or Disabled Carer Occupation: Employer: To see if you are eligible for a reduced rate, please answer the questions on page 8 Parent/Guardian Two Details Relationship to child: Mother Father Other Please Specify: Are you eligible to claim Child Care Benefit (CCB) and/or Child Care Rebate (CCR): Are you the parent/guardian who receives CCB through the Department of Human Services: First Name: Gender: Customer Reference Number (CRN): Address: Home Phone: Mobile: Work Phone: Work Status: Working Looking for work Studying/Training Disability or Disabled Carer Occupation: Employer: To see if you are eligible for a reduced rate, please answer the questions on page 8 6

7 Authorised minee is a person, over 18 years old, who has the parents/guardians permission to collect the child from an education and care service, should the parent/guardians be unavailable, in the event of an incident, injury, trauma, illness, emergency, etc AT LEAST ONE AUTHORISED NOMINEE MUST BE NAMED. Authorised minee One Relationship to child: First Name: Gender: Address: Home Phone: Mobile: Work Phone: Authorised minee Two Relationship to child: First Name: Gender: Address: Home Phone: Mobile: Work Phone: I give my permission for the above nominees to collect my child/ren from care should the parent/guardians listed not be available to collect my child/ren from care. Parent Signature: Date: Medical Information Name of Doctor: Address of Doctor: Phone: Medicare Number: Private Health Insurance: * *Membership Number: Name of Fund: Ambulance Insurance: * *Membership Number: I give permission for the program to seek information from the doctor/medical centre named above about how to manage any allergy or medical condition experienced by my child/ren. * Parent Signature: Date: 7

8 Parent/Guardian One Details Are you a Communities@Work staff member Address of Employer: Do you work for an employeee sponsored organisation? Name of organisation: Please provide proof of employment letter with your enrolment Parent/Guardian Two Details Are you a Communities@Work staff member Address of Employer: Do you work for an employeee sponsored organisation? Name of organisation: Please provide proof of employment letter with your enrolment If you have an Assessment tice from the Department of Human Services and there are siblings listed on the Assessment tice and those siblings attend another approved long day care, family day care or school age care program, please complete the following so the multiple child CCB percentage can be applied to your account. Child Care Benefit (CCB) and Child Care Rebate (CCR): First Name: Name of other program: Child 1 Child 2 Child 3 Total number of children who attend approved long day care, family day care or school age care programs or any combination of these services in the same week: Do you wish to claim the multiple CCB percentage for these children at this service? I understand it is my responsibility to notify the children s services enrolment team in writing should the number of children claiming the multiple CCB percentage change for my family. Signature: Date: 8

9 Please tick which of the following service locations you would be interested in: Locations Amaroo Katherine Avenue, Amaroo P: E: Charles Weston - Coombs (not open during the Dec & Jan school holidays) 80 Woodberry Avenue, Coombs P: E: coombs@commsatwork.org Fadden Hanlon Cres, Fadden P: E: fadden@commsatwork.org Harrison Wimmera Street, Harrison P: E: harrison@commsatwork.org Isabella Plains Early Childhood Service For preschool students to year 2. Ellerston Avenue, Isabella Plains P: E: ipecs@commsatwork.org Monash Corlette Crescent, Monash P: E: monash@commsatwork.org Neville Bonner Mabo Boulevard, Bonner P: E: bonner@commsatwork.org Palmerston Kosciuszko Avenue, Palmerston P: E: palmerston@commsatwork.org Refer to Booking Form on page 12 to select the dates you require 9

10 Authorisations I authorise my child/ren to participate in all activities offered by the program: I consent for my child/ren to participate in local excursions e.g. walks to local parks and sports ovals under supervision of educators. tification will be provided for any excursions involving the use of transport or away from the program: I give permission for my child/ren to be transported by Communities@Work bus fleet or Communities@Work car as required: In the event of an accident, injury, trauma or illness, I consent to my child/ren being given medical treatment in an emergency situation from a registered medical practitioner, hospital or ambulance service. I consent to my child/ren being transported by ambulance to hospital, if required. I agree to meet any medical and ambulance expenses incurred: I understand and accept that medication can only be administered to my child/ren when authorisation has been given by the parent/guardian or authorised nominees detailed on this enrolment form authorisation will not be accepted from any person not listed on this form: I consent to the administration of a bronchodilator using an inhaling device if my child/ren should suddenly collapse and/or have difficulty in breathing: I consent to my child/ren being removed from the school holiday program in the event of an emergency evacuation, and may be relocated to another venue as instructed by emergency services families will be notified in this instance: I consent to my child/ren to have photographs taken for program displays, a means of recording observations and future planning: I consent to my child/ren to have photographs taken for Communities@Work promotional material: I consent to my child/ren to have photographs taken for Communities@Work s social media: In accordance with Cancer Council recommendations, I consent for SPF30+ sunscreen to be applied to all unprotected areas of skin on my child/ren for outside play: I consent for my child/ren to view G or PG rated programs (TV, DVD, videos or movies) and play G or PG rated computer games: I am aware the Communities@Work Out of School Hours Care Policy and Procedure Manual is available at the program and can be accessed at any time. 10

11 Parent/Guardian Terms and Conditions I/We and (insert parent/guardian names) agree to the following terms and conditions: 1. Pay all fees and charges by the due date for any account rendered, and understand that the accepted method of payment is via direct debit arrangements with Ezidebit. I/We understand that in the event of financial hardship, special arrangements may be made on application to the manager, children s services enrolments team. I/We understand that Communities@Work is entitled to the recovery of outstanding fees plus additional costs incurred (inclusive of commission) to a collection agency for recovery action. 2. I/we understand if I/we do not receive a statement from the children s services enrolments team or believe a statement is incorrect, I/we are responsible from promptly notifying the children s services enrolments team. 3. I/we understand that an SMS will be sent to the mobile phone number of the person responsible for payment of the account should payment via Ezidebit decline. 4. Understand that the booking/enrolment will be cancelled if the account remains outstanding and will be forwarded to a collection agency for recovery. 5. Indemnify Communities@Work and any person associated with the education and care service in relation to any claim for damages as a result of an accident, injury or trauma to my child/ren unless it is the direct result of negligence on the behalf of Communities@Work or associated persons. 6. I/we understanding, that Child Care Benefit and Child Care Rebate cannot be applied to my fees if my child/ ren is absent on his/her first and last day(s) and full fees will be charged. 7. I/we understand, that Child Care Benefit and Child Care Rebate can only be applied to my child/ren s first forty two (42) absence days, any additional absence days will be charged at full fees, unless additional absence reasons apply and relevant supporting documentation is provided. 8. I/we understand that a late fee of $20.00 per child for every fifteen (15) minutes or part thereof will be charged for children picked up after 6.00pm. 9. I/we understand that the advertised program activities may change without notice. 10. I/we understand that Communities@Work abides by the federal governments Priority of Access Guidelines, and my child/ren may be required to vacate the program should a child with a higher priority require a placement. 11. I/we understand once enrolment has been processed, confirmation will be given by or phone. refunds will be given on any amendments or cancellations after confirmation. Refunds will only be given for cancellations if a doctor s certificate is supplied. The refund only applies to the child s name that appears on the certificate. 12. I/we acknowledge fees may be reviewed and changed at anytime. Updated enrolment forms and/or booking agreement forms shall notify families in these instances. 13. In line with the Communities@Work Vision, Mission and Values (available at I/we agree to respect and show courtesy in all dealings with Communities@Work staff, and families and children within the education and care service. I/we acknowledge any forms of discriminatory or threatening behaviours are not acceptable. 14. The information I/we have provided on this form is correct, and understand it is my/our responsibility to update details should they change. Parent/Guardian 1 Signature: Parent/Guardian 2 Signature: Date: Date: Please note: Enrolments will not be processed unless signatures from both parents/guardians listed on this form have accepted the Terms and Conditions. Please return all pages, completed, to the children s services enrolments team, allowing seven (7) days for processing before required commencement date. 11

12 Booking Form Parents/Guardians must complete this form. Please complete ALL INFORMATION on BOTH SIDES of this application in BLOCK LETTERS. Parent Details Given Names: Phone: Locations Please tick which of the following service locations you would be interested in: Services in grey open before Christmas and may remain open after Australia Day. Please note dates below. Amaroo (19-21 Dec, 3-27 Jan)* Katherine Avenue, Amaroo Charles Weston - Coombs (not open during the Dec & Jan school holidays) Fadden (3-25 Jan) Hanlon Cres, Fadden Harrison (3-25 Jan) Wimmera Street, Harrison Isabella Plains Early Childhood Service (19-21 Dec, 3-25 Jan) For preschool students to year 2. Ellerston Avenue, Isabella Plains Monash (19-21 Dec, 3-27 Jan)* Corlette Crescent, Monash Neville Bonner (3-25 Jan) Mabo Boulevard, Bonner Palmerston (3-25 Jan) Kosciuszko Avenue, Palmerston Please tick the days you would like your child/ren to attend the program Child 1 Mon Tues Wed Thurs Fri Mon Tues Wed Thurs Fri Week 1 19/12* 20/12* 21/12* N/A N/A Week 2 Pub. Hol. Pub. Hol. N/A N/A N/A Child 1 Mon Tues Wed Thurs Fri Mon Tues Wed Thurs Fri Pub. 3/1 4/1 5/1 6/1 9/1 10/1 11/1 12/1 13/1 Week 3 Week 4 Hol. Child 1 Mon Tues Wed Thurs Fri Mon Tues Wed Thurs Fri Week 5 16/1 17/1 18/1 19/1 20/1 Week 6 23/1 24/1 25/1 Pub. Hol. Child 2 Mon Tues Wed Thurs Fri Mon Tues Wed Thurs Fri Week 1 19/12* 20/12* 21/12* N/A N/A Week 2 Pub. Hol. Pub. Hol. 27/1* N/A N/A N/A Child 2 Mon Tues Wed Thurs Fri Mon Tues Wed Thurs Fri Pub. 3/1 4/1 5/1 6/1 9/1 10/1 11/1 12/1 13/1 Week 3 Week 4 Hol. Child 2 Mon Tues Wed Thurs Fri Mon Tues Wed Thurs Fri Week 5 16/1 17/1 18/1 19/1 20/1 Week 6 23/1 24/1 25/1 Pub. Hol. 27/1* Office Use Only Enrolments Team Signature: Date: Comments/Follow Up: PO BOX 1066, TUGGERANONG ACT 2901 P: E: enrolments@commsatwork.org

13 Direct Debit Request Bank Account New Customer *Indicates a Mandatory Field BUSINESS ABN/ACN Communities@Work CUSTOMER REFERENCE N/A *SURNAME *FIRST NAME MOBILE PHONE *ADDRESS * Debit Arrangement / Payment Details I authorise and request NumeroPro Pty Ltd (Direct Debit User ID: ) to debit payments from my nominated account through the Bulk Electronic Clearing System (BECS), as specified below, at intervals and amounts as directed by CHILDCARE CENTRE NAME with the Terms and Conditions of this agreement. Child s Name Amount $ Balance Due FIXED VARIABLE WEEKLY FORTNIGHTLY MONTHLY 4 WEEKLY Start Date DD/MM/YYYY e.g. 25 Sep 2016 Debit from Bank, Building Society or Credit Union Account Financial Institution Branch BSB Number Account Number Account Holder Name/s I/We authorise NumeroPro Pty Ltd ABN to debit my/our account at the Financial Institution identified above through the Bulk Clearing System (BECS) in accordance with the Payment details stated above and as per the NumeroPro Pty Ltd Direct Debit Request Service Agreement provided. Transaction Fee: $0.79 By signing and/or providing us with a valid instruction in respect to your Direct Debit Request, you have understood and agreed to the Terms and Conditions governing the debit arrangements between you and NumeroPro Pty Ltd as set out in this Request and in your Direct Debit Request Service Agreement. Signature/s of minated Account Holder Date Date DD/MM/YYYY e.g. 25 Sep 2016 DD/MM/YYYY e.g. 25 Sep 2016 OFFICE USE ONLY Received Date: Reference.: Ver 6.0 COMPLETE USING BLACK INK ONLY

14 Direct Debit Request SERVICE AGREEMENT Bank Account The following is your Direct Debit Service Agreement with NumeroPro Pty Ltd APCA ID ABN The agreement is designed to explain what your obligations are when undertaking a Direct Debit arrangement with us. It also details what our obligations are to you as your Direct Debit Provider. We recommend you keep this agreement in a safe place for future reference. It forms part of the terms and conditions of your Direct Debit Request (DDR) and should be read in conjunction with your DDR form. Definitions (a) account means the account held at your financial institution from which we are authorised to arrange for funds to be debited. (b) agreement means this Direct Debit Request Service Agreement between you and us. (c) Business means the business as referred to on the DDR form (d) banking day means a day other than a Saturday or a Sunday or a public holiday listed throughout Australia. (e) debit day means the day that payment by you to us is due. (f) debit payment means a particular transaction where a debit is made. (g) direct debit request means the Direct Debit Request between us and you. (h) us or we means NumeroPro &/or NumeroPro Pty Ltd, (the Debit User) you have authorised by signing a direct debit request. (i) you means the customer who signed the Direct Debit Request. (j) your financial institution means the financial institution nominated by you on the DDR at which the account is maintained. (k) Sponsor Bank means the bank sponsoring NumeroPro Pty Ltd as a debit user in the direct debit system. I/We hereby authorise NumeroPro Pty Ltd ABN (herein referred to as NumeroPro ) to make periodic debits on behalf of the Business as indicated on the front of this Direct Debit Request (herein referred to as the Business ). I/We acknowledge that NumeroPro is acting as a Direct Debit Agent for the Business and that NumeroPro does not provide any goods or services and has no express or implied liability in regards to the goods and services provided by the Business or the terms and conditions of any agreement that I/we have with the Business. I/We acknowledge that the debit amount will be debited from my/our account according to the terms and conditions of my/our agreement with the Business. I/We acknowledge that bank account and/or credit card details have been verified against a recent bank statement to ensure accuracy of the details provided and will contact my/our financial institution if I/we are uncertain of the accuracy of these details. Debiting Your Account You should refer to the Direct Debit Request and this agreement for the terms of the arrangement between us and you. We will only arrange for funds to be debited from your account as authorised in the Direct Debit Request. If the debit day falls on a day that is not a banking day, we may direct your financial institution to debit your account on the following banking day. If you are unsure about which day your account has or will be debited you should ask your financial institution. Amendments By Us We may vary any details of this agreement or a Direct Debit Request at any time by giving you at least fourteen (14) days written notice. Amendments By You You may change, stop or defer a debit payment, or terminate this agreement by providing us with at least fourteen (14) days notification by writing to: to PO Box 6309 GCMC QLD 9726 or by telephoning us on during business hours or arranging it through your own financial institution. Your Obligations It is your responsibility to ensure that there are sufficient clear funds available in your account to allow a debit payment to be made in accordance with the Direct Debit Request. If there are insufficient clear funds in your account to meet a debit payment: (a) you may be charged a fee and/or interest by your financial institution; (b) you may also incur fees or charges imposed or incurred by us; and (c) you must arrange for the debit payment to be made by another method or arrange for sufficient clear funds to be in your account by an agreed time so that we can process the debit payment. You should check your account statement to verify that the amounts debited from your account are correct. If NumeroPro is liable to pay goods and services tax ("GST") on a supply made in connection with this amount equal to the consideration payable for the supply multiplied by the prevailing GST rate. I/We acknowledge that there may be a delay in processing if: (a) there is a public or bank holiday on the day, or any day after the debit date; (b) a payment request is received by NumeroPro on a day that is not a banking business day in Queensland; and (c) a payment request is received after normal NumeroPro cut off times, being 4:00 pm Queensland time, Monday to Friday. Any payments that fall due on any of the above will be processed on the next business day. Dispute If you believe that there has been an error in debiting your account, you should notify us directly on and confirm that notice in writing with us as soon as possible so that we can resolve your query more quickly. Alternatively you can take it up with your financial institution direct. If we conclude as a result of our investigations that your account has been incorrectly debited we will respond to your query by arranging for your financial institution to adjust your account (including interest and charges) accordingly. We will also notify you in writing of the amount by which your account has been adjusted. If we conclude as a result of our investigations that your account has not been incorrectly debited we will respond to your query by providing you with reasons and any evidence for this finding in writing. Accounts You should check: (a) with your financial institution whether direct debiting is available from your account as direct debiting is not available on all accounts offered by financial institutions. Direct Debit, through BECS, is not available on all accounts. (b) your account details which you have provided to us are correct by checking them against a recent account statement; and (c) with your financial institution before completing the Direct Debit Request if you have any queries about how to complete the Direct Debit Request. Confidentiality We will keep any information (including your account details) in your Direct Debit Request confidential. We will make reasonable efforts to keep any such information that we have about you secure and to ensure that any of our employees or agents who have access to information about you do not make any unauthorised use, modification, reproduction or disclosure of that information. Further information relating to NumeroPro s Privacy Policy can be found at We will only disclose information that we have about you: (a) to the extent specifically required by law; or (b) for the purposes of this agreement (including disclosing information in connection with any query or claim). (c) if the Sponsor Bank requests such information to be provided in the event of a claim or relating to an incorrect or wrongful debit.

15 Direct Debit Request Credit Card New Customer *Indicates a Mandatory Field BUSINESS ABN/ACN Communities@Work CUSTOMER REFERENCE N/A *SURNAME *FIRST NAME MOBILE PHONE *ADDRESS * Debit Arrangement / Payment Details I authorise and request NumeroPro Pty Ltd (Direct Debit User ID: ) to debit payments from my nominated account through the Bulk Electronic Clearing System (BECS), as specified below, at intervals and amounts as directed by with the Terms and Conditions of this agreement. CHILDCARE CENTRE NAME Child s Name Amount $ Balance Due FIXED VARIABLE Start Date WEEKLY FORTNIGHTLY MONTHLY 4 WEEKLY Debit from Credit Card Card Number Expiry Date Card Type Card Holders Name/s By signing this form, I/we authorise NumeroPro Pty Ltd, acting on behalf of the Business, to debit payments from my specified credit card above, and I/we acknowledge that NumeroPro Pty Ltd will appear as the business name on my credit card statement. Furthermore, I/we agree to reimburse NumeroPro Pty Ltd for any successful claims made by the Card Holder through their financial institution against NumeroPro Pty Ltd. Transaction Fee: 1.5% + $0.10 This Authorisation is to remain in force in accordance with the terms and conditions on this Direct Debit Request, the provided NumeroPro Pty Ltd DDR Service Agreement, and I/we have read and understood the same. Signature/s of minated Credit Card Holder Date Date DD/MM/YYYY e.g. 25 Sep 2016 DD/MM/YYYY e.g. 25 Sep 2016 OFFICE USE ONLY Received Date: Reference.: Ver 6.0 COMPLETE USING BLACK INK ONLY

16 Direct Debit Request SERVICE AGREEMENT Credit Card The following is your Direct Debit Service Agreement with NumeroPro Pty Ltd APCA ID ABN The agreement is designed to explain what your obligations are when undertaking a Direct Debit arrangement with us. It also details what our obligations are to you as your Direct Debit Provider. We recommend you keep this agreement in a safe place for future reference. It forms part of the terms and conditions of your Direct Debit Request (DDR) and should be read in conjunction with your DDR form. Definitions (a) account means the account held at your financial institution from which we are authorised to arrange for funds to be debited. (b) agreement means this Direct Debit Request Service Agreement between you and us. (c) Business means the business as referred to on the DDR form (d) banking day means a day other than a Saturday or a Sunday or a public holiday listed throughout Australia. (e) debit day means the day that payment by you to us is due. (f) debit payment means a particular transaction where a debit is made. (g) direct debit request means the Direct Debit Request between us and you. (h) us or we means NumeroPro &/or NumeroPro Pty Ltd, (the Debit User) you have authorised by signing a direct debit request. (i) you means the customer who signed the Direct Debit Request. (j) your financial institution means the financial institution nominated by you on the DDR at which the account is maintained. (k) Sponsor Bank means the bank sponsoring NumeroPro Pty Ltd as a debit user in the direct debit system. You should check your account statement to verify that the amounts debited from your account are correct. If NumeroPro is liable to pay goods and services tax ("GST") on a supply made in connection with this amount equal to the consideration payable for the supply multiplied by the prevailing GST rate. I/We acknowledge that there may be a delay in processing if: (a) there is a public or bank holiday on the day, or any day after the debit date; (b) a payment request is received by NumeroPro on a day that is not a banking business day in Queensland; and (c) a payment request is received after normal NumeroPro cut off times, being 4:00 pm Queensland time, Monday to Friday. Any payments that fall due on any of the above will be processed on the next business day. Dispute If you believe that there has been an error in debiting your account, you should notify us directly on and confirm that notice in writing with us as soon as possible so that we can resolve your query more quickly. Alternatively you can take it up with your financial institution direct. If we conclude as a result of our investigations that your account has been incorrectly debited we will respond to your query by arranging for your financial institution to adjust your account (including interest and charges) accordingly. We will also notify you in writing of the amount by which your account has been adjusted. If we conclude as a result of our investigations that your account has not been incorrectly debited we will respond to your query by providing you with reasons and any evidence for this finding in writing. I/We hereby authorise NumeroPro Pty Ltd ABN (herein referred to as NumeroPro ) to make periodic debits on behalf of the Business as indicated on the front of this Direct Debit Request (herein referred to as the Business ). I/We acknowledge that NumeroPro is acting as a Direct Debit Agent for the Business and that NumeroPro does not provide any goods or services and has no express or implied liability in regards to the goods and services provided by the Business or the terms and conditions of any agreement that I/we have with the Business. I/We acknowledge that the debit amount will be debited from my/our account according to the terms and conditions of my/our agreement with the Business. I/We acknowledge that bank account and/or credit card details have been verified against a recent bank statement to ensure accuracy of the details provided and will contact my/our financial institution if I/we are uncertain of the accuracy of these details. Debiting Your Account You should refer to the Direct Debit Request and this agreement for the terms of the arrangement between us and you. We will only arrange for funds to be debited from your account as authorised in the Direct Debit Request. If the debit day falls on a day that is not a banking day, we may direct your financial institution to debit your account on the following banking day. If you are unsure about which day your account has or will be debited you should ask your financial institution. Amendments By Us We may vary any details of this agreement or a Direct Debit Request at any time by giving you at least fourteen (14) days written notice. Amendments By You You may change, stop or defer a debit payment, or terminate this agreement by providing us with at least fourteen (14) days notification by writing to: to PO Box 6309 GCMC QLD 9726 or by telephoning us on during business hours or arranging it through your own financial institution. Your Obligations It is your responsibility to ensure that there are sufficient clear funds available in your account to allow a debit payment to be made in accordance with the Direct Debit Request. If there are insufficient clear funds in your account to meet a debit payment: (a) you may be charged a fee and/or interest by your financial institution; (b) you may also incur fees or charges imposed or incurred by us; and (c) you must arrange for the debit payment to be made by another method or arrange for sufficient clear funds to be in your account by an agreed time so that we can process the debit payment. Accounts You should check: (a) with your financial institution whether direct debiting is available from your account as direct debiting is not available on all accounts offered by financial institutions. Direct Debit, through BECS, is not available on all accounts. (b) your account details which you have provided to us are correct by checking them against a recent account statement; and (c) with your financial institution before completing the Direct Debit Request if you have any queries about how to complete the Direct Debit Request. Confidentiality We will keep any information (including your account details) in your Direct Debit Request confidential. We will make reasonable efforts to keep any such information that we have about you secure and to ensure that any of our employees or agents who have access to information about you do not make any unauthorised use, modification, reproduction or disclosure of that information. Further information relating to NumeroPro s Privacy Policy can be found at We will only disclose information that we have about you: (a) to the extent specifically required by law; or (b) for the purposes of this agreement (including disclosing information in connection with any query or claim). (c) if the Sponsor Bank requests such information to be provided in the event of a claim or relating to an incorrect or wrongful debit. Credit Card Payments I/we acknowledge that Business will appear as the merchant for all payments from my/our credit card. I/We acknowledge and agree that NumeroPro will not beheld liable for any disputed transactions resulting in the non-supply of goods and/or services and that all disputes will be directed to the Business as NumeroPro is acting as a 3rd party payment provider. I/We acknowledge and agree that in the event that a claim is made, NumeroPro will not be liable for the refund of any funds and agree to reimburse NumeroPro for any successful claims made the Card Holder throught their financial institution against NumeroPro. Credit Card Fees are in mimimum of the Transaction or the Credit Card Fee whichever is greater. I/We authorise: a) NumeroPro to verify details of my/our account with my/our financial institution; and b) My/our financial institution to release information allowing NumeroPro to verify my/our account details.

17 Out of School Hours Care Enrolment Form Once this form is completed please to Phone: Postal Address: PO Box 1066, Tuggeranong, Enrolment Form