IHC Full Registration Form - Australia’s Leading Home Care Agency

Parent/ Guardian 1(Required)

First Name Last Name

Gender(Required)

Occupation(Required)

Date of Birth(Required)

DD slash MM slash YYYY

CRN(Required)

(Required)

Street Address Suburb State Post Code

Mobile Phone(Required)

Work Phone

Home Phone

Parent/ Guardian 1 Email(Required)

Combined Annual Family Taxable Income(Required)

Child Care Subsidy Percentage:(Required)

Please enter a number from 0.00 to 100.00.

Is this a single parent household?(Required)

Yes

Parent/ Guardian 2

First Name Last Name

Gender

Occupation

Date of Birth

DD slash MM slash YYYY

CRN

Mobile Phone

Work Phone

Parent/ Guardian 2 Email

Emergency Contact Information

I authorise the below emergency contacts

to consent to medical treatment and/or authorise administration of medication to the child on my behalf
to be contacted in the event of an emergency if I cannot be immediately contacted
to consent to my child/ren to be taken to external locations with the educator
to consent for my child/ren to be transported in a vehicle by the educator/service or by other transportation as arranged by the educator/service

Emergency Contact 1 Name(Required)

First Name Last Name

Mobile Number(Required)

Relationship to you(Required)

Specific Instructions(Required)

Emergency Contact 2

Emergency Contact 2 Name(Required)

First Name Last Name

Mobile Number(Required)

Relationship to you(Required)

Specific Instructions(Required)

Child Information

Please fill in fully each section for as many children you have.

Child 1 Name(Required)

First Name Last Name

Gender(Required)

Date of Birth(Required)

DD slash MM slash YYYY

CRN(Required)

Parent/ Guardian 1 relationship to Child(Required)

Parent/ Guardian 2 relationship to Child

PLEASE INCLUDE AS MUCH DETAIL AS POSSIBLE

Educators are provided this information to assist them with their Education and Planning.

Describe any Allergies AND management methods

Describe any Dietary Restrictions AND management methods

Describe any Behaviour Alerts AND management methods

Describe any Disabilities AND support required

Describe any Medical Conditions AND list medications, administration schedule, dosages etc.

Is Medication Prompt Required?(Required)

Yes

Is Medication Assistance Required?(Required)

Yes

Is Medication Administration Required?(Required)

Yes

Describe Developmental Status (e.g. breast, bottle, eating solids, crawling, walking, sleeping/eating patterns)

Describe Hobbies, Interests, Likes, Dislikes, Personality Traits

Child 2 Name

First Name Last Name

Gender

Date of Birth

DD slash MM slash YYYY

CRN

Parent/ Guardian 1 relationship to Child

Parent/ Guardian 2 relationship to Child

PLEASE INCLUDE AS MUCH DETAIL AS POSSIBLE

Educators are provided this information to assist them with their Education and Planning.

Describe any Allergies AND management methods

Describe any Dietary Restrictions AND management methods

Describe any Behaviour Alerts AND management methods

Describe any Disabilities AND support required

Describe any Medical Conditions AND list medications, administration schedule, dosages etc.

Is Medication Prompt Required?

Yes

Is Medication Assistance Required?

Yes

Is Medication Administration Required?

Yes

Describe Developmental Status (e.g. breast, bottle, eating solids, crawling, walking, sleeping/eating patterns)

Describe Hobbies, Interests, Likes, Dislikes, Personality Traits

Child 3 Name

First Name Last Name

Gender

Date of Birth

DD slash MM slash YYYY

CRN

Parent/ Guardian 1 relationship to Child

Parent/ Guardian 2 relationship to Child

PLEASE INCLUDE AS MUCH DETAIL AS POSSIBLE

Educators are provided this information to assist them with their Education and Planning.

Describe any Allergies AND management methods

Describe any Dietary Restrictions AND management methods

Describe any Behaviour Alerts AND management methods

Describe any Disabilities AND support required

Describe any Medical Conditions AND list medications, administration schedule, dosages etc.

Is Medication Prompt Required?

Yes

Is Medication Assistance Required?

Yes

Is Medication Administration Required?

Yes

Describe Developmental Status (e.g. breast, bottle, eating solids, crawling, walking, sleeping/eating patterns)

Describe Hobbies, Interests, Likes, Dislikes, Personality Traits

Child 4 Name

First Name Last Name

Gender

Date of Birth

DD slash MM slash YYYY

CRN

Parent/ Guardian 1 relationship to Child

Parent/ Guardian 2 relationship to Child

PLEASE INCLUDE AS MUCH DETAIL AS POSSIBLE

Educators are provided this information to assist them with their Education and Planning.

Describe any Allergies AND management methods

Describe any Dietary Restrictions AND management methods

Describe any Behaviour Alerts AND management methods

Describe any Disabilities AND support required

Describe any Medical Conditions AND list medications, administration schedule, dosages etc.

Is Medication Prompt Required?

Yes

Is Medication Assistance Required?

Yes

Is Medication Administration Required?

Yes

Describe Developmental Status (e.g. breast, bottle, eating solids, crawling, walking, sleeping/eating patterns)

Describe Hobbies, Interests, Likes, Dislikes, Personality Traits

Child 5 Name

First Name Last Name

Gender

Date of Birth

DD slash MM slash YYYY

CRN

Parent/ Guardian 1 relationship to Child

PLEASE INCLUDE AS MUCH DETAIL AS POSSIBLE

Educators are provided this information to assist them with their Education and Planning.

Describe any Allergies AND management methods

Describe any Dietary Restrictions AND management methods

Describe any Behaviour Alerts AND management methods

Describe any Disabilities AND support required

Describe any Medical Conditions AND list medications, administration schedule, dosages etc.

Is Medication Prompt Required?

Yes

Is Medication Assistance Required?

Yes

Is Medication Administration Required?

Yes

Describe Developmental Status (e.g. breast, bottle, eating solids, crawling, walking, sleeping/eating patterns)

Describe Hobbies, Interests, Likes, Dislikes, Personality Traits

Child 6 Name

First Name Last Name

Gender

Date of Birth

DD slash MM slash YYYY

CRN

Parent/ Guardian 1 relationship to Child

Parent/ Guardian 2 relationship to Child

PLEASE INCLUDE AS MUCH DETAIL AS POSSIBLE

Educators are provided this information to assist them with their Education and Planning.

Describe any Allergies AND management methods

Describe any Dietary Restrictions AND management methods

Describe any Behaviour Alerts AND management methods

Describe any Disabilities AND support required

Describe any Medical Conditions AND list medications, administration schedule, dosages etc.

Is Medication Prompt Required?

Yes

Is Medication Assistance Required?

Yes

Is Medication Administration Required?

Yes

Describe Developmental Status (e.g. breast, bottle, eating solids, crawling, walking, sleeping/eating patterns)

Describe Hobbies, Interests, Likes, Dislikes, Personality Traits

Child 7 Name

First Name Last Name

Gender

Date of Birth

DD slash MM slash YYYY

CRN

Parent/ Guardian 1 relationship to Child

Parent/ Guardian 2 relationship to Child

PLEASE INCLUDE AS MUCH DETAIL AS POSSIBLE

Educators are provided this information to assist them with their Education and Planning.

Describe any Allergies AND management methods

Describe any Dietary Restrictions AND management methods

Describe any Behaviour Alerts AND management methods

Describe any Disabilities AND support required

Describe any Medical Conditions AND list medications, administration schedule, dosages etc.

Is Medication Prompt Required?

Yes

Is Medication Assistance Required?

Yes

Is Medication Administration Required?

Yes

Describe Developmental Status (e.g. breast, bottle, eating solids, crawling, walking, sleeping/eating patterns)

Describe Hobbies, Interests, Likes, Dislikes, Personality Traits

Required Hours

So that we can give you the most accurate cost estimate possible, we need a snap shot, a sample scenario of the most typical or common example of the hours that you would require a nanny to work on a regular weekly basis. Fill in the times based on the longest hours you would require on any given day. Include the time it takes to travel to and from work / study / training.

Monday

Shift 1 Start Time

Hours

Minutes

AM/PM

Shift 1 Finish Time

Hours

Minutes

AM/PM

Shift 2 Start Time

Hours

Minutes

AM/PM

Shift 2 Finish Time

Hours

Minutes

AM/PM

Tuesday

Shift 1 Start Time

Hours

Minutes

AM/PM

Shift 1 Finish Time

Hours

Minutes

AM/PM

Shift 2 Start Time

Hours

Minutes

AM/PM

Shift 2 Finish Time

Hours

Minutes

AM/PM

Wednesday

Shift 1 Start Time

Hours

Minutes

AM/PM

Shift 1 Finish Time

Hours

Minutes

AM/PM

Shift 2 Start Time

Hours

Minutes

AM/PM

Shift 2 Finish Time

Hours

Minutes

AM/PM

Thursday

Shift 1 Start Time

Hours

Minutes

AM/PM

Shift 1 Finish Time

Hours

Minutes

AM/PM

Shift 2 Start Time

Hours

Minutes

AM/PM

Shift 2 Finish Time

Hours

Minutes

AM/PM

Friday

Shift 1 Start Time

Hours

Minutes

AM/PM

Shift 1 Finish Time

Hours

Minutes

AM/PM

Shift 2 Start Time

Hours

Minutes

AM/PM

Shift 2 Finish Time

Hours

Minutes

AM/PM

Saturday

Shift 1 Start Time

Hours

Minutes

AM/PM

Shift 1 Finish Time

Hours

Minutes

AM/PM

Shift 2 Start Time

Hours

Minutes

AM/PM

Shift 2 Finish Time

Hours

Minutes

AM/PM

Sunday

Shift 1 Start Time

Hours

Minutes

AM/PM

Shift 1 Finish Time

Hours

Minutes

AM/PM

Shift 2 Start Time

Hours

Minutes

AM/PM

Shift 2 Finish Time

Hours

Minutes

AM/PM

Will this be the same time each week on a regular basis?(Required)

Yes

If you selected No, please outline the details of irregularity(Required)

Are you flexible with the days and times required?(Required)

Yes

If you selected Yes, please outline the details of flexibility(Required)

When would you like care to commence?

Commencement Date(Required)

DD slash MM slash YYYY

Is this position ongoing?(Required)

Yes

If No, possible finish date?(Required)

DD slash MM slash YYYY

Do you plan to bring your own educator?(Required)

Yes

Describe your family’s preferred daily routine, along with any specific requirements regarding care (e.g. toilet training, use of certain equipment, children’s household duties etc.)(Required)

Describe your family’s lifestyle matters (e.g. cultural/religious values and preferences, immune-suppressed environment, custody orders etc.)(Required)

Is this a live in position?(Required)

Yes

Will there be any driving required?(Required)

Yes

If yes, is the Educator required to use their own car?(Required)

Yes

First Language Spoken at Home(Required)

Second Language

Do you have any pets?(Required)

Yes

If yes, details of Pets

Do you have a swimming pool?(Required)

Yes

Saftey At Home

Is this is a smoke free home?(Required)

Yes

Are there any environmental hazards in the home we should be aware of? (e.g. renovations, multi-story etc.)(Required)

Yes

If yes, details of Environmental Hazards

Will the family accept responsibility for taking all responsible care to protect the staff member form all forms of abuse by family members and guests?(Required)

Yes

Are there any custody orders in place for your children?(Required)

Yes

If yes, details of Custody Orders

Are there other people living in the home other than you, your partner (if applicable) and children?(Required)

Yes

If yes, details of Other People Living in the Home

In Home Care

Have you spoken to the In Home Care Support Agency?(Required)

Yes

Who is your Family Liaison Officer?

Have you created a Family Management Plan?(Required)

Yes

Confirmation

Confirmation(Required)

Yes

Confirmation I confirm that all information completed within my Registration form is true and accurate. I also agree to allow ALHCA to share my information with Educators, the In Home Care Support Agency, the Department of Education, the Department of Human Services, Child Care Subsidy Help Desk and Software Providers, fellow Service Providers, ACCS referral organisations and other authorised personnel. I also give authorisation for my Educator to seek medical treatment for my child by a registered medical practitioner, hospital or ambulance service and if required, transport the child to hospital.

IHC Full Registration

Parent/ Guardian 2

Emergency Contact Information

Emergency Contact 2

Child Information

PLEASE INCLUDE AS MUCH DETAIL AS POSSIBLE

PLEASE INCLUDE AS MUCH DETAIL AS POSSIBLE

PLEASE INCLUDE AS MUCH DETAIL AS POSSIBLE

PLEASE INCLUDE AS MUCH DETAIL AS POSSIBLE

PLEASE INCLUDE AS MUCH DETAIL AS POSSIBLE

PLEASE INCLUDE AS MUCH DETAIL AS POSSIBLE

PLEASE INCLUDE AS MUCH DETAIL AS POSSIBLE

Required Hours

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

When would you like care to commence?

Saftey At Home

In Home Care

Confirmation

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