Barmi Class Enrolment Form

PARENT INFORMATION

Mothers full name Mobile
Address Email
Fathers full name   Mobile
Address Email
Home phone     

Is the Natural Mother of the Child Jewish?  Yes No  
Are there any conversions in the family?    
Yes No 
If yes, please specify whom and through what organisation.
  
  

CENTERLINK CHILDCARE REBATE / BENEFIT
Most families are able to get at least the CCR %50 rebate from the government. In order to get the rebate you need to be registered with Centrelink and have a CRN (Customer reference number) for yourself and your child. This can be done by calling 136 150. Please note there are 2 applicable rebate/benefits: CCR (not means tested, available to most families) and CCB (means tested, depends on your income). For more information on the rebates, click on
www.humanservices.gov.au


To claim CCR and/or CCB Centrelink rebate/benefit please provide: 
Parent CRN    
Parent DOB    
Parent Name corresponding to CRN
   
 

Childs Details:
 
First Name:   Last Name:
Hebrew Name:
Date Of Birth dd/mm/yyyy:  
Name of School Currently Attending:  
Grade (2015):  

Medical Conditions (Asthma, Diabetes etc.) (Type N/A if none) 
Please email
[email protected] relevant medical management plan.
Drug/Food allergies (Type N/A if none)
Please email
[email protected] relevant medical management plan. 
Medicare Card Number:
Child's # on card:  Medicare Expiry:
Private Health Fund Name:  
Membership #:

To Claim Centrelink Funding:

Child Name:
Child CRN:  

EMERGENCY CONTACT
Contact Relationship to child
Phone Mobile


Local G.P. Name
G.P. Phone/Mobile  

 

I UNDERSTAND THAT IN THE CASE OF EMERGENCY ATTEMPT WILL BE MADE TO CONTACT MYSELF WHEN PRACTICAL. I AGREE TO PAY FOR ANY COST THAT MAY OCCUR AS A RESULT OF INJURY OR ILNESS. I ACKNOWLEDGE THAT MY CHILD WILL BE PARTICIPATING IN PROGRAM ACTIVITIES WITHIN AND OUTSIDE THE PROGRAM CENTRE. I AUTHORISE MY CHILD TO PARTICPATE IN THESE ACTIVITIES. I AGREE TO PAY FOR ANY RECKLESS DAMAGE DONE BY MY CHILD AT THE PROGRAM. I HEREBY AUTHORISE CHABAD MALVERN TO PHOTOGRAPH MY CHILD DURING THE PROGRAM AND TO USE THE PHOTOGRAPHS AT THEIR DISCRETION.

Signed:

Payment Details:

I would like to help Chabad Malvern Hebrew School save administration costs by selecting to pay with direct debit using the credit card listed below. (Your card will be debited in the middle of each term after Centrelink benefits have been assesed)  

 

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Welcome to our secure online payment system - pay online 24 hours a day, 6 days a week. It's that simple!

Simply fill out the form below and click the button to submit your payment.

*Method of Payment:

Type of

*Name On Card:

*Card Number:

*Expiration Month: *Year:

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