Playgroup - Registration - Childhood Cancer Association

Step 1 of 3
Children details

Children

Add all children that will be attending the playgroup

Child

First name

Last name

Country of birth

(optional)

Is this child the patient?

Yes

Diagnosis

(if child is the patient)

Expected treatment completion date

(if child is the patient)

What is the reason for non-attendance at traditional playgroup/preschool?

Does your child have any special needs?

Does the child speak a language other than English at home?

If yes, what language(s) other than English are spoken at home?

Has your child previously attended a formal educational setting?

(e.g. playgroups, child care, kindy, preschool)

Yes

Which formal educational setting?

(if yes)

Frequency

(if yes)

What did they like best about going?

Step 2 of 3
Contact details

Parent/Guardian details

Primary caregiver name

First name

Last name

Relationship to child

Email address

Phone number

Address

Emergency contact details

Emergency contacts

Enter in order of priority. Minimum 2 emergency contacts.

First name

Last name

Relationship to child

Phone number

Address

First name

Last name

Relationship to child

Phone number

Address

Step 3 of 3
Consent

Photo consent

Photos - Newsletter, Promotional, Advertising Materials, and Grant

I do give consent

I do not give consent

for:

Photographs of my family and/or child/ren taken at the Playgroup to be used by the Childhood Cancer Association (CCA) for the following purposes: Newsletter, Promotional and Advertising Materials (e.g. Facebook, Instagram, website, promotional DVD, posters, pamphlets, display/promotional materials, conference presentations). Photographs of my family and/or child/ren taken at the Playgroup to be used by the Childhood Cancer Association (CCA) as part of grant applications. Any photos taken and used for grant applications/reports will not be linked to any individualized data and so progress of individual children would not be identifiable.

Research & Grant Application Consent

Information - Grant applications

I do give consent

I do not give consent

for:

My child’s information to be used as part of any research that evolves from my child’s participation in the Playgroup.

I have been informed that, while information gained during this program may be published, neither my child nor any other family member will be identified, and no personal results will not be divulged at any time. I understand that all information will remain anonymous.

Please note: if you have consented to your photos being used as part of a grant application, the individual photos will not be linked to an individual child’s progress. While photos may be included in an application/report all data will remain anonymous and no names of individual children will be provided.

Confidentiality and Information Storage

All personal information gathered during the provision of the Playgroup will remain confidential and secure. All physical records will remain in secure storage at the Childhood Cancer Association. The facilitators (e.g. Early Educator Teacher, Playgroup SA) of the Playgroup will have access to your details to ensure that they are able to appropriately run the sessions. All facilitators may share relevant information with each other to ensure the effective running of the program.

Consent

I hereby consent to the registration of my child/ren in the Playgroup Program and understand and agree to the information outlined in this consent form and provided to me in the Playgroup Parents Handbook.

Name

First name

Last name

Signature

Date

Playgroup Registration Enquiry

Child

Parent/Guardian details

Emergency contact details

Photo consent

Research & Grant Application Consent

Confidentiality and Information Storage

Consent

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