Machon Bat Mitzvah Application

MACHON BAT MITZVAH APPLICATION ♦

Lamdeni, 569 Glenhuntly Road, Elsternwick, 3185 | T (03) 9524-7709 | F (03) 9524-7799

Note: Places are limited. To ensure your child’s place, fill out this form with a $100 non-refundable enrolment fee. Thank you.

BAT MITZVAH GIRL'S PERSONAL DETAILS

Full Name*

First Name Last Name

Hebrew Name

Date of Birth*

Day Month Year

Centrelink Reference Number (CRN)

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Lamdeni Are you currently enrolled for Hebrew Classes?

YesNo

Friends (optional) 2 friends you would like to have in your group (TBC)

PARENT DETAILS

Father's Full Name*

First Name Last Name

Date of Birth*

Day Month Year

Address*

Same as ChildOther

Other Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone (Home)

Area Code Phone Number

Phone (Work)

Area Code Phone Number

Mobile Number*

Area Code Phone Number

E-mail*

Main Language*

Jewish Status*

from birthConverted (Orthodox)Non Jewish

Country of Birth

AustraliaOther

Name of country

Mother's Full Name*

First Name Last Name

Date of Birth*

Day Month Year

Address*

Same as ChildOther

Other Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone (home)

Area Code Phone Number

Phone (work)

Area Code Phone Number

Mobile Number*

Area Code Phone Number

E-mail*

Main Language*

Marital Status*

Jewish Status*

from birthConverted (Orthodox)Non Jewish

Country of Birth

AustraliaOther

Name of country

Rabbi Officiating*

MEDICAL INFORMATION

Medicare Number*

Medicare Expiry Date*

Day Month Year

Number of Child on Card*

Child's Registered Medical Practitioner or Service Name

Practitioner's Name

Contact Numbers

Contact Numbers (1)

Contact Numbers (2)

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Do you have Private Health Cover?*

YesNo

Healthcare Provider

Healthcare Number

Do you have Ambulance Cover?*

YesNo

Does your child have any medical conditions?* (Asthma, Allergy, Anaphylaxis, Other)

YesNo

If yes, please provide a medical management plan, which the child's medical practitioner has prepared.

Note: This can be uploaded at the end of this form.

MEDICAL ACKNOWLEDGEMENTS

Medication will only be administered if it is in the original container with the original label and instructions that can be clearly read and before the expiry or use by date. Additionally, if the medication has been prescribed by a medical practitioner:

The label must contain the child's name and
Parents must provide any verbal or written instructions provided by the medical practitioner.

Education and Care Services National Regulations Regulation 95 Any medication, including non-prescription medication like paracetamol, must be authorised by parents or an authorised nominee on our "Administration of Authorised Medication" form. Education and Care Services National Regulations Regulation 93

I acknowledge this

Do you authorise the Nominated Supervisor or another educator at the centre to seek medical treatment from a registered medical practitioner, hospital or ambulance service?

Please Choose

YesNo

I acknowledge this

Do you authorise the Nominated Supervisor or another educator at the centre to seek dental treatment from a registered dental practitioner or service in the event of an emergency?

Please Choose

YesNo

I acknowledge this

Do you authorise the Nominated Supervisor or another educator to transport the child in an ambulance in the event of an emergency?

Please Choose

YesNo

I acknowledge this

Do you authorise that if the child is diagnosed with asthma or anaphylaxis and an emergency occurs, the Nominated Supervisor or other educators may administer emergency first aid without making contact. Educators will notify the child's parents and/or emergency services as soon as possible?

(Education and Care Services National Regulations - Regulation 94)

Please Choose

YesNo

Parent 1 Initials

Parent 2 Initials

IMMUNISATION DETAILS

Are your Child's Immunisation Up To Date? Please provide a copy of your child's Immunisation History Statement provided by Medicare. Note: This can be uploaded at the end of this form.

YesNo

TRANSPORTATION AUTHORISATION

Education and Care Services National Regulations - Regulation 102(4), 102D (4)

The centre will seek separate authorisations from a parent/carer or authorised person who is authorised to transport the child or arrange transportation for the child for:

regular outings (once every twelve months)
an excursion that is not a regular outing

Parent 1 Initial

Parent 2 Initial

COURT ORDER

Education and Care Services National Regulations - Regulation 160 (3c, d)

Are there any court orders, parenting orders or parenting plans relating to the powers, duties and responsibilities or authorities of any person in relation to the child or access to the child?

Please Choose

YesNo

Are there any other court orders relating to the child's residence or the child's contact with a parent or other person?

Please Choose

YesNo

Please note: Without this documentation we cannot legally enforce the Order/s.

Note: This can be uploaded at the end of this form.

FIRST EMERGENCY CONTACT/AUTHORISED NOMINEE

Education and Care Services National Regulations - Regulation 160 (3b, ii, iii, iv, v, vi) 161 (1a, I, ii, 1b)

An authorised nominee is an acknowledged person who, with the parents/guardian's authorisation, is allowed to give permission for the following:

Drop off/ collect the child if necessary (r160(3)(b)(iii)).
Authorise the taking of the child outside the service by an educator of the service (r160(3)(b)(v), r161(1)(a)(ii), & r102).
To authorise the service to take the child on a regular outing (r161(1)(b)).
Give consent to the medical treatment to the child (r160(3)(b)(iv)) r161(1).
Request or permit the administration of medication or authorises administration of medication or medical treatment to the child (r160(3)(b)(iv), r161(1)(a);
Consent to the transportation of the child by an ambulance service. (r161(1)(a)(ii))

Full Name

First Name Last Name

Relationship to the Child

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

E-mail Address

Home Phone Number

Mobile Phone Number

Work Phone Number

SECOND EMERGENCY CONTACT

Full Name

First Name Last Name

Relationship to the Child

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

E-mail Address

Home Phone Number

Mobile Phone Number

Work Phone Number

CHILD CARE SUBSIDY (CCS)

Child Care Subsidy will be paid directly to the centre to reduce the fees families pay. To claim Child Care Subsidy (CCS) Families must meet eligibility requirement which include:

Have you received confirmation about your Child Care Subsidy?

YesNo

Who applied for CCS?

FatherMother

CRN Number

Please Note: If you need assistance with filling out this form please speak to us. Please ensure that if any details change, you notify the centre immediately.

ENROLMENT AGREEMENT

PLEASE READ THE FOLLOWING AGREEMENT CAREFULLY BEFORE SIGNING. PLEASE ASK IF THERE IS ANYTHING IN THIS DOCUMENT THAT YOU ARE UNSURE OF.

Please tick the following items to authorise:

I/We give permission for this child to: Participate in outings to places of interest (permission slip will have to be signed (or authorised via WhatsApp, SMS or email) before allowing your child to leave the centre).

Please Choose

YesNo

For photos and video footage of my/our child to be used for centre usages on the centre website, social media and other purposes, such as advertisement and used in organisation's resources.

Please Choose

YesNo

Do you ONLY give permission for photos and video footage of your child to be taken for your own personal viewing and to receive copies.

Please Choose

YesNo

Please see attached document for information that is required to be added here.

ATTACHED DOCUMENTS

How did you hear about us?

Please specify

DECLARATION
EXCURSION: I give permission for my child to attend the excursions organised as part of the program (via Hamerkaz Youth).

I certify that all the above is true and correct and agree to the Program's terms and conditions.

I fully understand that this enrolment is accepted only on the basis of the full year program including the Batmitzvah Shabbaton and Ceremony and agree to pay the full annual fees accordingly. I authorise Lamdeni (or a Third Party) to charge my credit card accordingly. Government subsidies available. I also understand that the enrolment fee of $100 is non-refundable, and is not part of the annual fees.

To secure your place, please pay a non-refundable enrolment fee of*

$100 AUD

Payment*

⚠ You have not yet connected a credit card processor.

Credit Card Check/Cash

Postal / Zip Code

Country

Full Name*

First Name Last Name

Signature*

(Education and Care Services National Regulations - Regulation 94)

Confirmation & Signature

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Synagogue בית כנסת

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Bar Mitzvah בר מצווה

Youth נוער