Chabad Sparks Clubs Registration Form

Government Childcare Benefit and Childcare Rebate (of up to 50%) as well as subsidies are available. To ensure you receive your eligible benefit, please make sure to include the Centrelink number and Date of Birth of both the student and the parent when applying online. For both types of Government assistance, you will need to ensure your child is registered for Yeshivah Beth Rivkah Out of School Hours Care (Vacation Care).
IMPORTANT: If your child has not attended any overnight, day camps or clubs with Chabad Youth before please follow the link and enrol at chabadyouth.hubworks.com.au
We also require a copy of your childs immunisation record. This is a mandatory requirement before acceptance into any clubs.
For further information regarding government subsidies please contact Naomi or Ellie on 9528 8395 or email admin@chabadyouth.org. Please note: It is the responsibility of the parent to ensure we have the correct information in order to process your benefits. Your credit card will not be charged until after the benefits have been calculated.

Registration Information

Please take care when filling out the form that all information is correct. Incorrect information may result in your child not receiving a place in the clubs.

General Information:

Child First Name*

Child Middle Name

Child Last Name*

Gender* MaleFemale

Child Date of Birth*

Child Address*

Home Phone Number

School*

Grade (in 2019)*

I am attending Chabad Sparks Mini Chefs for $133 ($19 a session)
Wednesday

I am attending Chabad Sparks J-Art for $154 ($22 a session) Monday

Special Remarks

My childs' strengths, interests and abilities:

Parent 1 First Name*

Parent 1 Middle Name

Parent 1 Last Name*

Parent 1 Contact Number*

Parent 1 Email

Parent 2 First Name

Parent 2 Middle Name

Parent 2 Last Name

Parent 2 Contact Number

Parent 2 Email

Emergency Contact (other than Parents)

Emergency Contact Name*

Emergency Contact Number*

Emergency Contact Relationship*

Medical Information

IMPORTANT: WE REQUIRE A COPY OF YOUR CHILD'S IMMUNISATION RECORD PRIOR TO ACCEPTANCE INTO CLUBS.

Current GP Name*

Current GP Contact details*

Medicare: Name on Card*

Medicare: Child #*

Medicare Number*

Medicare Expiry Date*

Private Health Care Fund

Private Health Care Number

Current Medication*

Please include all reasons and dosages. If not applicable you must enter the words 'Not Applicable'

Allergies*

Please include all reactions. Any allergies included will require allergy action plans to be provided. If not applicable you must enter the words 'Not Applicable'

Medical Conditions*

If your child has a medical condition you are required to submit a medical condition management plan by email (admin@chabadyouth.org). If not applicable you must enter the words 'Not Applicable'

Special Remarks

PAYMENT INFORMATION:

Please note payment MUST be recieved BEFORE your child attends any clubs.

Government subsidies are available. Payment will be processed after childcare deductions have been calculated.If you choose to pay by another method leave the credit card form blank, however your child's place will not be confirmed until your payment has been received.(There is a 3% surcharge for American Express payments.)

Name on Credit Card

Credit Card Number

Expiry

CVV

Clubs Registration Form

Chabad Sparks Clubs Registration Form

Registration Information

General Information:

Emergency Contact (other than Parents)

Medical Information

IMPORTANT: WE REQUIRE A COPY OF YOUR CHILD'S IMMUNISATION RECORD PRIOR TO ACCEPTANCE INTO CLUBS.

OSHC AUTHORISATION FORM

Collecting your child from the Yeshivah Beth Rivkah OSHC premises

Please tick all that apply

Authorised Nominee #1

Authorised Nominee #2

Authorised Nominee #3

I hereby authorise Yeshivah/Beth Rivka OSHC staff and/or volunteers to photograph my child and use the photographs for any Yeshiva Beth Rivka OSHC for the following purposes:

PAYMENT INFORMATION:

Before you submit:

1. Have you answered all the questions in full?

2. Does your child have a hubworks profile? If you are unsure, check with the office.

3. Have you sent your child's immunisation record through, they will not be accepted into any clubs without it.

E- signature and date

Sign on the line with your mouse or finger