Please ask any member of the teaching team if you need help completing this form.

All personal information about your child will be stored securely and remain
confidential at all times.

Office Use only:

Early Learning Centre: Summerhill Early Learning Infocare Number:__________NSN:___________________________

Enrolment Date:_______________________Start Date:______________________Leaving Date:_____________________

Is your child on the waiting list at any other Kindergarten or Childcare? ☐ Yes  No

If YES please list the names of the other Kindergarten/Childcare:____________________________________________________

Application is made for the enrolment of:

Child’s official surname or family name:Di_____________________________________________________________________

Child’s official given name:Steven____________________________________________________________________________

Child’s official other names/middle names:Sichi_________________________________________________________________

(Please separate names with a comma)

Name your child is known by / preferred:

Surname / Family name:Di____________________________________________DiGiven Name:Chichi______________________

Child’s primary residential address:___________________________________________________________________________

Copy of official identity verification document* collected by staff:

 New Zealand birth certificate ☐ New Zealand passport ☐ Foreign birth certificate ☐ Foreign passport

☐ Other ______________________ Staff Initials:_________________

Child’s date of birth:06/12/2017____________________________  Male ☐ Female

Child’s ethnic origin/s:Chinese_______________________________________________________________________________

Iwi affiliations:____________________________________________________________________________________________

Language/s spoken at home:Chinese__________________________________________________________________________

Parents/Guardians:

Mother/Guardians Name: Jennifer Hou______________________________Relationship to Child:Mother_______________

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Home Address:11 Olympus Circle, Linton Camp, Palmerston North__________________________________________________

Phone Home:______________________________ Work:____________________________Mobile:0211855808______________

Email: [email protected]__________________________Allowed to Collect:  Yes ☐ No Account Payer:  Yes ☐ No

Father/Guardians Name: Houjie Di_____________________________________Relationship to Child:Father________________

Home Address: 11 Olympus Circle, Linton Camp, Palmerston North_________________________________________________

Phone Home:______________________________ Work:____________________________Mobile:0220459208______________

Email: [email protected]__________________aAllowed to Collect:  Yes ☐ No Account Payer:  Yes ☐ No

Emergency Contacts (authorised to collect child)

Name:Qin Wang______________________________________ Relationship to Child: Grandma_____________________

Phone Home:____________________________ Work:__________________________Mobile:_______________________

Name:Jisheng Hou_____________________________________ Relationship to Child: Grandpa_____________________

Phone Home:____________________________ Work:__________________________Mobile:_______________________

Name:______________________________________________ Relationship to Child: _____________________________

Phone Home:____________________________ Work:__________________________Mobile:_______________________

Name:______________________________________________ Relationship to Child: _____________________________

Phone Home:____________________________ Work:__________________________Mobile:_______________________

Name:______________________________________________ Relationship to Child: _____________________________

Phone Home:____________________________ Work:__________________________Mobile:_______________________

Any Parenting or Court Orders relating to this child? ☐ Yes  No

Please note that to help enforce any Parenting Orders or Court Orders we require a copy to be kept at the Early Learning Centre.

Where did you hear about us?

☐ You or a member of your family attended a Ruahine Kindergarten/Early Learning Centre in the Past
☐ Ruahine Kindergarten Website ☐ Ruahine Facebook Page ☐ Newspaper advert/article

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 Recommendation/word of mouth ☐ Community Event
☐ Other – (Please specify)___________________________________

Child’s Doctor:Lo______________________________________Phone: 06-3547737__________________________________

Address:445 Ferguson Street, Palmerston North_________________________________________________________________

Allergies/illness/asthma/dietary requirements:

Please fill in any medication forms for long term medication when your child starts at the Early Learning Centre.

Additional needs: E.g. Autism, under SES

Immunisation up to date:  Yes ☐ No Copy of Immunisation Certificate provided:  Yes ☐ No

I give permission for staff to provide basic First Aid and change any wet/soiled clothes:  Yes ☐ No

Enrolment Details:

Date of Enrolment29/01/2020____________Date of Entry_____________________Date of Exit:______________________

Please note: 20 Hours ECE is for up to six hours per day, up to 20 hours per week and there must be no compulsory fees when a child is receiving 20
hours ECE funding.

Days Enrolled: Monday Tuesday Wednesday Thursday Friday Total Hours

Times Enrolled 10:30am- 12-6pm 12-6pm 20

4:30pm
e.g. 8:30am - 4:30pm

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 For 20 Hours ECE fill out boxes below with hours attending e.g. 6 hours

20 hours ECE
at this service

20 hours ECE
at another service

Parent/Guardian Signature:__________________________________________Date:__________________________________

Change of Days/Times of Enrolment:

Effective Date of Change: __________________________

Please note: 20 Hours ECE is for up to six hours per day, up to 20 hours per week and there must be no compulsory fees when a child is receiving 20
hours ECE funding.

Days Enrolled: Monday Tuesday Wednesday Thursday Friday Total Hours

Times Enrolled:
e.g. 8:30am - 4:30pm

For 20 Hours ECE fill out boxes below with hours attending e.g. 6 hours

20 hours ECE
at this service

20 hours ECE
at another service

Parent/Guardian Signature:___________________________________________Date:__________________________________

20 Hours ECE Attestation:

1. Is your child receiving 20 Hours ECE for up to six hours per day, 20 hours per week at this service? (Tick one)  Yes ☐ No
2. Is your child receiving 20 Hours ECE at any other services? (Tick one) ☐ Yes  No
If yes to either or both of the above, please sign to confirm that:

 Your child does not receive more than 20 hours of 20 hours ECE per week across all services.

 You authorise the Ministry of Education to make enquiries regarding the information provided in the Enrolment

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 Agreement Form, if deemed necessary and to the extent necessary, to make decisions about your child’s eligibility for 20
Hours ECE.

 You consent to the early childhood education service providing relevant information to the Ministry of Education, and to
other early childhood education services your child is enrolled at, about the information contained in this box.

Parent/Guardian Signature:_______________________________________Date:________________________________

Dual Enrolment Declaration:

I hereby declare that my child is/is not enrolled at another early childhood institution at the same times that he/she is enrolled
at Summerhill Early Learning

Parent/Guardian Signature: _______________________________________Date: ________________________________

Account Payer (Must be completed if neither Parent/Guardian are nominated as account payer):

Name:Jennifer Hou________________________________________________________________________________________

Address: 11 Olympus Circle, Linton Camp, Palmerston North_______________________________________________________

Phone: 0211855808_________________________________________ Email: [email protected]_________________________

Signature:______________________________________________________

Privacy Statement:

We are collecting personal information on this enrolment form for the purposes of providing early childhood education for
your child.
We will use and disclose your child’s information only in accordance with the Privacy Act 1993. Under that Act you have the
right to access and request correction of any personal information we hold about you or your child.
Details about your child’s identity will be shared with the Ministry of Education so that it can allocate a national student
number (NSN) for your child. This unique identifier will be used for research, statistics, funding, and the measurement of
educational outcomes.
You can find more information about national student numbers at: eli.education.govt.nz
* Information about acceptable identity verification documents is available online at eli.education.govt.nz
The Ministry recommends that all services keep a copy of the identity verification document of each child who is enrolled at
the service

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Fee Contract Declaration:

Families who are not using all of their 20 hours ECE at this Early Learning Centre will be asked to pay a fee for each hour of
attendance that is not attested for the Ministry of Education 20 hours ECE rate.

● I have read a copy of the Whānau Information Booklet, which explains the fees, funding and attendance requirements. I
have read and understood the Terms of Trade and agree to pay any fees arising from my child’s enrolment by Friday of
the week following, in accordance with the payment terms detailed in the Terms of Trade agreement.

● I understand that a minimum of two weeks’ notice must be given if a child is leaving the Early Learning Centre and that a
penalty equivalent to two weeks’ fees may be incurred if this notice is not given.

● Optional charges are one-off or ongoing charges for services, activities or items that are over and above the mandatory
level of service required from ECE providers. Optional charges are for, but not limited to the following: Sports/music,
Excursions. I understand that if I do not pay the optional charge my child will not be disadvantaged; however they will
not have access to these ‘extras’.

● I understand that nappies and wipes, any formula/breast milk and bottles are to be provided by myself for my child.

● I understand that if I am paying fees that I will still be charged for statutory holidays.

Parent/Guardian Signature:_______________________________________ Date:_______________________________

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Permissions:

1. I understand that the Early Learning Centre teachers are responsible for my child only during licensed hours.
2. I am responsible for ensuring that my child gets safely to and from the Early Learning Centre, accompanied by
a person who must be aged 14 years and over.
3. I have read, understood and agree to the Early Learning Centre’s Excursion Policy and confirm that I need to
view Risk Assessments and give written approval any time my child has to travel for a trip or excursion.
4. I understand my child may be taken to an alternative location during an emergency situation e.g. Civil Defence
Welfare Centre or other safe place.
5. I understand my child’s portfolio will be accessible to my child and my family and that I will respect the
confidentiality of other children’s documents.
6. I give permission for samples of my child’s work to be used in displays, either at the Early Learning Centre or in
the community.  Yes ☐ No
7. I give permission for my child to go for walks with the staff in the area around the Early Learning Centre (the
ratio for these outings will be 1 adult to 4 children).  Yes ☐ No
8. I agree to my child using or being involved with the use of ICT, including supervised internet usage, as part of
the learning environment.  Yes ☐ No
9. I give permission for my details to be shared with the Early Learning Centre Committee for fundraising
purposes and to enable communication about Early Learning Centre or community events  Yes ☐ No
10. I give permission for my child’s name and date of birth to be given to the school they will be attending
Name of School: _____________________________  Yes ☐ No
11. I give permission for teachers to apply sunscreen to my child when necessary (child attending 6 hours only)
 Yes ☐ No
12. I give permission for photos and videos of my child to be used in Early Learning Centre displays, and other
learning related purposes.  Yes ☐ No
13. I give permission for photos and videos of my child to be used to be used to promote the RKA. For example
Facebook, website, newsletter and flyers ☐ Yes ☐ No
14. I give permission for my child’s photos and videos to be viewed by other parents on Educa e.g. group learning
stories.  Yes ☐ No
Statutory Holidays/Christmas Break

Ruahine Early Learning Centres do not operate on Statutory Holidays or during the week between Christmas and New Years
Day. Please ask your teachers for exact dates each year.

‘Up With The Play’

I give permission to receive an electronic copy of Ruahine Kindergartens’ termly newsletter - Up With The Play and provide my
email address: [email protected]__________________________________

Other Information

Policy Statement: Ruahine Early Learning Centres has a number of policies and procedures in place for the care and education
of children. The signing of this enrolment agreement form indicates that you will abide by the policies of this service, and
understand how you can have input to policy review.

Parent/Guardian Signature: _______________________________________Date:________________________________

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Parent/Guardian Declaration:

I Jennifer Hou_____________________ declare that all the above information is true and correct to the best of my knowledge.

Parent/Guardian Signature: _______________________________________Date:________________________________

Service Declaration:

I Jennifer Hou_____________________on behalf of Ruahine Kindergarten Association, declare that this form has been checked
and all required parts completed.

Manager Signature: _____________________________________________Date:________________________________

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 Optional Charges

Office Use only:

Early Learning Centre:__________________________________Child’s Name:_____________________________________________

Infocare Number:_____________________________________

Optional Charges:

The Optional charges are one-off or ongoing charges for services, activities or items that are over and above the mandatory level of
service required from ECE providers. Optional charges are for, but not limited to the following:

1. Optional Charges are:

 Excursions and Entrance Fees
 Entertainers
 Transportation
 Specific resources e.g. provision for music or sports tuition

2. I understand that if I agree to pay for the optional charge, Ruahine Kindergarten Association may enforce payment.

3. The agreement to pay the optional charge will last for the time my child attends a Ruahine Early Learning Centre

4. The rules about making changes to the agreement are:

 The agreement to pay the optional charge may be reviewed by parents annually.

5. I understand that the optional charge is not compulsory and if I choose not to pay there will be no penalty.

6. I agree/do not agree (select one) to pay the optional charge for the activities/items specified in this enrolment agreement
form.

7. I understand that where I choose not to pay optional charges, I am agreeing for my child to not have access to those
additional services, activities or items. There will be no restriction to my child’s attendance at Early Learning Centre.

Parent/Guardian Signature:_____________________________________________Date:____________________________________

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Parent and Guardian Consent Form

Dear Parent/Guardian,
Portfolios are an invaluable tool to track the learning of your children. However, with your
busy lives, you are often rushed to read and hear about your child’s day. Online E-Portfolios allow you to access your
child’s portfolio from your home or work computer at any time. You are able to make comments, read learning stories
and newsletters, and share this information with other family members you have given authorized access to.
Educa is a secure web-based portfolio system specifically designed for New Zealand Early Childhood Education Centres
and parents. It significantly improves communication with parents and whānau. The idea behind Educa is to provide a
secure and interactive environment where teachers and parents/whānau can share learning stories, photos and videos,
and collaborate on children’s learning. Educa has also released apps for both the iPhone and the Android, which are
available for parents to follow children’s learning on the go.
To begin using Educa we’d like to have your permission for uploading photos, videos, learning stories and artwork of your
child to Educa. Please also provide your email address so we can send you an invitation to join Educa. If you require
access for other family members, please provide their full name, relationship to the child and email address in the Other
family Member Information section.

Centre Name Centre Name of child: Steven Sichi Di

As the parent, guardian or responsible adult for the above child, I consent to the above child care centre’s collection, use
and display of my child’s information on the Educa Application in accordance with the Privacy Policy set out on the Educa
website: http://www.educa.co.nz/privacy-policy.

________________________
Signature

Date: Date

Name: Jennifer Hou Relationship to child: Mother

Email Address: [email protected]

Other Family Member Information:

Full Name: Houjie Di Relationship to child: Father

Email Address: [email protected]

Full Name: Relationship to child:

Email Address:

Full Name: Relationship to child:

Email Address:

Full Name: Relationship to child:

Email Address:

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 ICT/Cybersafety
Agreement for
Parents/Caregivers
We define ICT as any device used to enhance the learning environment including computers, printers, ipads, cameras, cell
phones, the wireless network, MP3 players, software, etc.

Rules and Responsibilities

I understand that:
 Use of the Ruahine Kindergarten Association (RKA) computer network, Internet access facilities, computers and
other RKA-owned ICT equipment/devices (including mobile phones) on or off the RKA site, is restricted to:
a) RKA staff who have signed an ICT/Cybersafety use agreement.
b) Committee/Parent Group members, who have signed an ICT/Cybersafety use agreement.
c) Persons contracted to carry out work at the centre and at the discretion of the head teacher such as
ESWs, student teachers, technicians etc.
d) RKA-related activities.
e) Personal usage by RKA staff which is appropriate to the RKA learning environment and of a reasonable
amount.

 If I use my own camera/phone to take pictures/videos of my child at the Kindergarten/Early Learning

Centre/Home-Based environment I will not take any of other children without their parents’ permission.
 My Kindergarten/Early Learning Centre/Home-Based environment do their best to enhance learning through the
safe use of ICT. This includes working to restrict access to inappropriate, illegal or harmful material on the
internet or ICT equipment/devices within the educational environment or during educational based related
activities.
 My Kindergarten/Early Learning Centre/Home-Based environment will immediately respond to any Cybersafety
breaches in an appropriate manner;
 I have access to the ICT/Cybersafety Policy at any time and I know that my Kindergarten/Early Learning
Centre/Home-Based environment welcomes enquiries from parents/whānau about cybersafety issues.
 I cannot install my own software or programmes on any RKA ICT equipment.
 I am responsible for who I share the access/viewing of my child’s Educa portfolio.
 I understand that any breaches of this User Agreement will be investigated and may require a response by RKA
management, which could include, where necessary, referral to a law enforcement agency.

Name: Parent / Guardian

Signature:

Date:

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