Alternate Location Permission Request

Parent/Guardian(Required)

First Name Last Name

Email(Required)

Educator(Required)

First Name Last Name

Email(Required)

Submitted By(Required)

Supporting Information

To receive IHC at an alternate location, the Department of Education requires our Service to include quite specific information in the application. To avoid lots of back and forth, our Service collects as much information as possible e.g. even down to the allocated campsite number and coordinates.

Children related to this Alternate Location Permission Request(Required)

Child Name

Age

Exceptional Circumstances for the Request(Required)

Name of School(Required)

Reason family requires In Home Care delivery at an Alternate Location(Required)

Describe the type of Work/Study/Training AND why it cannot take place at the primary residence(Required)

Describe the medical circumstances AND why treatment cannot be sought locally to the primary residence(Required)

Describe the Natural Disaster/Displacement that prevents care taking place at the primary residence(Required)

Describe what seasonal factors influence the requirement for the family to relocate to an alternate/secondary home/location(Required)

Describe the renovation risks that you believe prevent care from taking place at the primary residence(Required)

Session Times at Alternate Location(Required)

will be as usual for all children

will be modified slightly for all children with the approval of the IHC Service

will be modified slightly for all children with the approval of the IHC Service, but will not overlap with any distance education direct contact sessions

will be usual for all non-school age children AND slightly modified for school aged children with the approval of the IHC Service, but will not overlap with any distance education direct contact sessions

Educators role at Alternate Location(Required)

caring for younger children who do not attend school

providing care outside of school or distance education session times

caring for younger children who do not attend school or distance education AND providing care to school aged children with the approval of the IHC Service, but will not overlap with any distance education direct contact sessions

Family Status(Required)

single Parent/Guardian home

two Parent/Guardian home

Parental Attendance at Alternate Location(Required)

both Parents/Guardians will be present at Alternate Location

only one Parent/Guardian will be present at the Alternate Location

Reason why the parent remaining at the Primary Location is unable to care for any children who do not need to attend the Alternate Location(Required)

Reason why the parent remaining at the Primary Location may be unavailable for handover at the beginning or end of In Home Care sessions(Required)

PARENT ONE Alternate Location Activity(Required)

Activity at the Alternate Location during IHC sessions of care

paid work, including being self employed

volunteering to support child development at event

undertaking training to support child development

undertaking course, education or study related to work

unpaid work experience or unpaid internship

actively setting up a business

actively looking for work

Other

Provide further details about the activity the parent will be undertaking at the Alternate Location(Required)

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PARENT ONE - Alternate Location Activity(Required)

Description of the activity the parent will be undertaking at the Alternate Location

PARENT TWO Alternate Location Activity(Required)

Activity at the Alternate Location during IHC sessions of care

paid work, including being self employed

volunteering to support child development at event

undertaking training to support child development

undertaking course, education or study related to work

unpaid work experience or unpaid internship

actively setting up a business

actively looking for work

Other

Provide further details about the activity the parent will be undertaking at the Alternate Location(Required)

This field is hidden when viewing the form

PARENT TWO - Alternate Location Activity(Required)

Description of the activity the parent will be undertaking at the Alternate Location

Accommodation Details

Accommodation Type(Required)

Description of facilities available at location, e.g. bathrooms, pool, kitchen, playground, etc(Required)

Name of Park/Hotel/Motel(Required)

Room, Cabin or Site Number(Required)

Alternate Location Address

Street Address Suburb State / Territory Post Code

Coordinates of Alternate Address (if relevant)

Enter date periods where the alternate location and all listed details remain the same e.g same location, children, purpose, and parental activity

This field is hidden when viewing the form

Date period(s) where application details are identical e.g same location, children, purpose, and parental activity

How many date periods will there be where Alternate Location Details are identical?(Required)

Start Date

Until

End Date

Start Date 1

End Date 1

Start Date 2

End Date 2

Start Date 3

End Date 3

Start Date 4

End Date 4

General overview of circumstances that explain the need for care at the Alternate Location rather than the Primary Location(Required)

Declaration and Emergency Contacts

Mandatory Conditions for Care at an Alternate Location:
    • Educator may only provide care to IHC enrolled children from the specific family they have been linked to
    • Educator must supervise children in shared areas (e.g. toilet or shower blocks, pool or playground areas, kitchen or indoor play areas etc.)
    • Educator must have completed an ALTERNATE LOCATION SAFETY AND HAZARD ASSESSMENT form prior to provision of care
    • Educator must carry an electronic or physical copy of the Alternate Location Safety assessment and Hazard management form with them
    • Educator must have completed a location specific LOCKDOWN, EVACUATION AND EMERGENCY PLAN prior to provision of care
    • Educator must carry an electronic or physical copy of the location specific Lockdown, Evacuation or Emergency plan with them
    • Educator must have access to the Harmony platform where asthma, anaphylaxis and medical plans are stored
    • Educator must carry a charged phone, power bank and first aid kit in their excursion toolkit
    • Educator must have access to or carry all mandatory resources (policy and record keeping booklet, contact information, safety equipment)
    • Educator must carry an electronic or physical copy of all emergency parent, service and other contact information
    • Educator must complete Adhoc Excursion forms should care be required outside of the Alternate Location Environment

Emergency Contacts

Local Health Service Address(Required)

Local Health Service Number(Required)

Address for local medical services(Required)

Local Police Station Address(Required)

Local Police Station Number(Required)

Local Fire Station Address(Required)

Local Fire Station Number(Required)

Submission of this application confirms that all conditions outlined above have been discussed, agreed to, and will be followed by both the Family and Educator prior to and during care at the alternate location.

Supporting Information

Accommodation Details

Enter date periods where the alternate location and all listed details remain the same e.g same location, children, purpose, and parental activity

Date period(s) where application details are identical e.g same location, children, purpose, and parental activity

Start Date

Until

End Date

Declaration and Emergency Contacts

Emergency Contacts

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