Child’s Details:
  1. Name your child is known by / preferred name:

  2. Copy of official identity verification document* collected by staff:

    New Zealand birth certificateForeign birth certificateNew Zealand passportForeign passportOther

  3. MaleFemale
  4. Child’s primary residential address:
Parents / Guardians:
Additional person/s who can pick up your child:
Custodial Statement
  1. Person(s) who cannot pick up your child:

Additional Emergency Contacts (also able to pick up child):
Child’s doctor:


  1. YesNo
  2. YesNo
  3. YesNo
  4. YesNo
  1. Category (i) Medicines

  2. A category (i) medicine is a non-prescription preparation (such as arnica cream, antiseptic liquid, insect bite treatment) that is not ingested, used for the ‘first aid’ treatment of minor injuries and provided by the service and kept in the first aid cabinet.
    Note: The service must provide specific information about the category (i) preparations that will be used.

  3. YesNo
  1. Category (ii) Medicines

  2. Category (ii) medicines are prescription (such as antibiotics, eye/ear drops etc) or non-prescription (such as paracetamol liquid, cough syrup etc) medicine that is used for a specific period of time to treat a specific condition or symptom, provided by a parent for the use of that child only or, in relation to Rongoa Māori (Māori plant medicines), that is prepared by other adults at the service.

    I acknowledge that written authority from a parent is to be given at the beginning of each day a category (ii) medicine is to be administered, detailing what (name of medicine), how (method and dose), and when (time or specific symptoms/circumstances) medicine is to be given.

  1. Category (iii) Medicines

  2. To be filled in if your child requires medication as part of an individual health plan, for example for an on-going condition such as asthma or eczema etc and is for the use of that child only.

  3. YesNo
  4. When does the medicine need to be taken: (State time or specific symptoms)

Enrolment Details:
  1. Please Note: 20 Hours ECE is for up to six hours per day, up to 20 hours per week and there must be no compulsory fees when a child is receiving 20 Hours ECE funding.

  2. Days Enrolled:

For 20 Hours ECE fill out boxes below with the hours attested e.g. 6 hours

  1. 20 Hours ECE at this service

  1. 20 Hours ECE at another service

20 Hours ECE Attestation:
  1. YesNo
  2. YesNo
  3. If yes to either or both of the above, please sign to confirm that:

    (i) Your child does not receive more than 20 hours of 20 Hours ECE per week across all services.

    (ii) Your authorise the Ministry of Education to make enquiries regarding the information provided in the Enrolment Agreement Form, if deemed necessary and to the extent necessary to make decisions about your child’s eligibility for 20 Hours ECE.

    (iii) You consent to the early childhood education service providing relevant information to the Ministry of Education, and to other early childhood education services your child is enrolled at, about the information contained in this box.

Dual Enrolment Declaration
  1. I hereby declare that my child is/is not enrolled at another early childhood institution at the same times that he/she is enrolled at [insert name of service].

Optional Charges:
  1. 1. The optional charge is for the following activities or items with the charge of:

  2. Morning tea
  3. $5 Per week
  4. YesNo
  5. Afternoon tea
  6. $5 Per week
  7. YesNo
  8. Lunch
  9. $5 Per week
  10. YesNo
  11. 2. I understand that if I agree to pay for the optional charge, Li'l Champs Blockhouse Bay may enforce payment.

  12. 3. The agreement to pay the optional charge will be effective until the official cancellation of the enrolment with the centre.
  13. 4. The agreement could be changed under the following conditions:

    • 2 weeks written notice with acceptable reason for unable to pay the optional charge.
    • The child has not taken part in the activity with prior notice to the centre.
      • 5. I understand that that optional charge is not compulsory and if I choose not to pay there will be no penalty.

      • 6. I agree/do not agree (select one) to pay the optional charge for the activities/items specified in this enrolment agreement form.

Statutory Holidays / Term Breaks/ Emergency Close
  1. 1. This enrolment agreement is inclusive of school term breaks.

  2. 2. [Li'l Champs Blockhouse Bay] is NOT OPEN on the following public holidays if they fall on a weekday.

    Centre will be closed on statutory holidays and on a specific emergency situation preventing us from operating. (e.g. national lock-down or a flood or a fire)

  3. New Year’s DayDay after New Year’s DayWaitangi DayGood Friday
  4. Easter MondayANZAC DayQueen's BirthdayLabour Day
  5. Christmas DayBoxing DayLocal Anniversary DayMatariki
Required Information for Licensing Purposes
  1. (i)I consent for my child to have a Vision and Hearing Test .Your consent will also allow the results of the test to be entered on to the B4School database.

    (ii) Excursions: Local excursion and short walk, regular local walk and a play in the neighbouring park will be undertaken. The “person responsible” will access the risk and complete a risk assessment form.

    Regular Excursions Adult and Children ratio will be 1:4 I agreeI don't agree

    (iii) Photo/video: permission for the child to be photographed for the purposes of assessment, planning and evaluation (explain clearly how the photos/videos can/can’t be used).

    We seek your agreement to the following amendment to the privacy statement (on page 1).

    “All personal information of your child will be kept securely and remain confidential, unless hereby you approve the use of undertaking activities photographs of Li'l Champs Blockhouse Bay children on Facebook or our website.”

Other information possible to include on this Enrolment Agreement Form
  1. (i) Policy Statement: Li'l CHamps Blockhouse Bay branch has a number of policies that set out the procedures that are in place for the care and education of the children who attend. We strongly urge you to read these. The signing of this enrolment agreement form indicates that you will abide by the policies of this service, and understand how you can have input to policy review.

    (ii) Parent Information Book: Please ensure you have read the information in the parent handbook as it covers such things as fee details, subsidies that are available to you and ways in which we can help you and your child settle into the service.

    (iii) Child’s strengths, interests and preferences: Please tell us about your child’s strengths, interests and preferences.

    (iv) Transitional School Visits: Information on transition arrangements.

    (v) Correspondence School Enrolment: Details of enrolment agreement.

Parent Declaration
  1. I declare that all the above information is true and correct to the best of my knowledge.

Service Declaration
Change of Days/Times of Enrolment
  1. Days Enrolled:

For 20 Hours ECE fill out boxes below

  1. 20 Hours ECE at this service

  1. 20 Hours ECE at another service

How did you hear about this?

  1. Website
  2. Yellow Pages
  3. Signage
  4. Parent
  5. Friend
  6. Flyer
  7. Localist
Documents Required on enrolment

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