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) 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 Please Select... Master Card American Express Visa Bankcard *Name On Card: *Card Number: *Expiration Month: *Year: Before pressing the "submit" button, press the "Print" button on your browser to print this page for your records. This page uses 128 bit SSL encryption to keep your data secure.