Enrolment Form "*" indicates required fields Groups Attending* Craft / Child Minding iKidz Playgroup Other If other, please indicate belowName* First Last Date of Birth* MM slash DD slash YYYY Birth Place* AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country of Birth Gender*MaleFemalePrefer not to sayOtherAddress* Street Address Suburb Postcode Phone Number*Email* Arrival Date in Australia MM slash DD slash YYYY Visa TypeMain language Spoken at home*Do you identify as*AboriginalTorres Strait IslanderNeitherBothHousehold composition*SingleCoupleSingle parent with childrenCouple with childrenLiving with others not related to youDo you have a disability, impairment or condition?* Intellectual Psychiatric Sensory/Speech Physical/Diverse None Other If other, please indicate below*Are you registered with NDIS?* Yes No Please give details of any medical conditions you would like us to be aware of*Please give details of any allergies or foods you do not eat*Emergency contact detailsEmergency contact name*Relationship to you*Phone Number*Parents Name (for child enrolment only)*Agreement to Participate in Group ProgramI give permission for photos/video of myself or my child(ren)’s to be taken when participating in a Pathways group. I understand that this material may be used on future Pathways documents.* Yes No Group Guidelines:* I agree to follow direction of staff whilst attending a group at Pathways offices or at other premises to ensure the comfort and safety of the entire groupDrugs and alcohol* I understand that this is a drug and alcohol free group and cigarette smoking is only allowed in the designated areas. *Group Participation* I agree to participate in as many activities as I am physically, mentally and emotionally able to do and to encourage and help others in the group.Supervision Responsibility* I acknowledge that I am responsible for the care and supervision of my child(ren) unless they are taken into a separate group activity.Emergency First Aid* I consent to the administering of first aid treatment for myself or my child(ren) in the case of a medical emergency by a certified senior first aid staff member. In the event of an injury or illness to me or any member of my family, I give approval for any necessary medical treatment carried out by a legally qualified medical practitioner. Should this be necessary, I understand that my emergency contact will be notified as soon as possible. I have full knowledge of the risks involved in attending and participating in this group and I/We and my child(ren) have no physical or medical condition which has the potential to put myself, my family or any other person at risk during the group. I understand that attendance at the group and undertaking any activities whatsoever involves a level of risk and that injury may occur. By agreeing to attend and participate, I waive any future right for me, my child(ren) or family member to claim negligence, except for that which cannot be excluded by law.Other important informationPrivacy Statement The primary purpose of collecting this information is to enable Pathways Community Care to adequately care for your child. All information regarding Children is sensitive information within the terms of the national Privacy principles under the Privacy Act. The information collected is used by Pathways Community Care for the aforementioned purpose. By law, those attending group are entitled to ask for and receive a copy of any personal information Pathways Community Care holds about them. Should they wish to access this information, or withdraw consent, they can do so by forwarding a written request to the activity’s coordinator. This will be arranged within 14 days of receiving the request.Mandatory reporting All staff are mandatory reporters, which means that they are legally obliged to report any child safety issues under the Children and Young Persons (Care and Protection) Act 1998 (the Care Act). If you have any questions regarding this, please speak with staff who will help you.Dex Consent The information that we collect from you on this form includes your personal information. Your personal information is protected by law, including by the Commonwealth Privacy Act. The client management system that we are using is an IT system called the ‘Data Exchange’. This system is hosted by the Australian Government Department of Social Services (DSS). Your personal information that is stored by DSS on the Data Exchange will only be disclosed to us for the purposes of managing your case. You are not required to provide your personal information to DSS. If you do not consent to the collection of your personal information, this will not affect the services provided to you. If you provide your personal information to DSS, you can ask for this information to be removed by DSS at any time. DSS de-identifies your data. The Data Exchange is used to produce information for policy development, grants program administration, and research and evaluation purposes. This includes producing reports for sharing with organisations. This information will not include information that identifies you, or information that can be used to re-identify you, in any way. You can find more information about the way DSS will manage your personal information in DSS’s privacy policy, which DSS has published on its website: https://www.dss.gov.au/privacy-policy . This policy contains information about how you may access the personal information about you that is stored on the Data Exchange and seek correction of that information. This policy also includes the circumstances in which DSS may disclose personal information to overseas recipients, as well as information about how you may complain about a breach of the Australian Privacy Principles by DSS, and how DSS will deal with your complaint.Consent for Parent or Adults completing this form: I consent to Pathways Community storing my personal information I consent for my personal information to be stored in the Data Exchange. I consent to participate in follow up research, surveys, or evaluations: I have read and understand the information regarding Staff being Mandatory Reporters I have read and understood my rights and responsibilities and details regarding privacy information and have been given the opportunity to ask questions. Consent* I agree*CAPTCHA
