Application for Submission – Child Development Center

Child's Particulars
Date of Admission:
Type of Care Programme: Full-Time Part-Time
Name as in Birth Certificate/Passport:
ID Type:
If choose Others, please specify:
Race:
If choose Others, please specify:
Date of Birth:
Birth Certificate No.:
Nationality:
If choose Others, please specify:
Birth Order:
No. of Siblings in Family:
Sex (M/F):MaleFemale
Contact No.:
Address/Tel:
Is child in a children's home?:YesNo
Organisation Name/Address
(if child is being enrolled by an organisation):
Mother's/Guardian's Particulars
Name as in NRIC/Passport:
NRIC/Passport No.:
Nationality:
If choose Others, please specify:
Date of Birth:
Race:
If choose Others, please specify:
Address:
Home Contact No.:
Mobile No.:
Marital Status:
Relationship with child:
Highest Educational Qualification (optional):
Email ID:
Employment Status:Working (56 hours or more per month)
Not Working (less then 56 hours per month)
Total hours of work per month:
Gross Monthly Income:
Designation/Occupation:
Employment Details (If working for 56 hours or more per month):
Employer's Name/Address:
Office Contact No.:
Fax No.:
Applying for Goverment child care subsidy:YesNo
With Effect From:
Father's Particulars (Optional)
Name as in NRIC/Passport:
NRIC/Passport No.:
Nationality:
If choose Others, please specify:
Date of Birth:
Race:
If choose Others, please specify:
Address:
Home Contact No.:
Mobile No.:
Marital Status:
Relationship with child:
Highest Educational Qualification (optional):
Email ID:
Employment Status:Working (56 hours or more per month)
Not Working (less then 56 hours per month)
Total hours of work per month:
Gross Monthly Income:
Designation/Occupation:
Employment Details (If working for 56 hours or more per month):
Employer's Name/Address:
Office Contact No.:
Fax No.:
Applying for Goverment child care subsidy: Yes No
With Effect From:
Medical Information
Please enclose photocopies of your child vaccination/immunisation certificate, indicating the dates i.e. poliomyelitis, trip antigen, measles and types of vaccinations.
Has your child had any convulsion (fits) with high fever?: Yes No
Any record of serious accidents, illness or hospitalisation?
If yes, please specify:
Yes No
 
Is your child currently on any drug or medication?
If yes, please specify:
Yes No
 
Past history of infectious Disease(If yes, please specify date):
a. Chicken Pox Yes No
Date:
b. Asthma? Yes No
Date:
c. Mumps Yes No
Date:
d. Persistent Cough Yes No
Date:
Others (Please Specify)
Allergy:
a. Drugs Yes No
b. Food Yes No
c. Others Yes No
Physical Disabilities:
a. Speech Yes No
b. Sight Yes No
c. Hearing Yes No
d. Movement Yes No
Others (Please Specify)
Family's Doctor
Doctor's Name:
Name of Clinic:
Contact No.:
Address:
Social Information
Parent Living:
Favourite toys, activities:
Opportunities to mix with other children:
Present care arrangment of child:
Child Spoken Languages:
Toilet Trained:
Self Feeding:
Food Dislike:
Emergency
In Case of emergency when both parents cannot be contacted, please call any persons named below:
Name:
NRIC/Passport No.:
Relationship to child:
Address:
Home No.:
Office No.:
Mobile No.:
Consent
Medical Authorisation
In the event that I cannot be reached at the time of illness or accident, permission is hereby granted to Bethel Child Development Centre and its staff to call a licensed physician of their selection or if hospitalisation is needed, my child will be sent to the nearest hospital and the medical fees and any other expenses such as transportation incurred on behalf of my child will be borne by me.
General Permission
In the event of any supervised field trips, excursions, outings or while my child is at the centre, I will not hold the Centre or its staff responsible for any unfortunate accident, injuries, loss of personal items or lives.
Consent (Continue)
General Permission(continue)
The following named individual is the only person authorised to pick up my child at the Centre. I will not hold the Centre for any damages, claims or liabilities which might result from the Centre and its staff releasing my child to any persons named below:-
Name:
NRIC/Passport No.:
Relationship to child:
Home No.:
Office No.:
Mobile No.:
I declare that the information provided in this application by me is true and I furnish it knowing that I may be liable to prosecution if I have wilfully stated any information which I know to be false or do not believe to be true. I also understand that any part of this application improperly completed may lead to the rejection of the application.
I hereby consent to the Ministry of Social And Family Development releasing my particulars and those of my child/children presently in the childcare centre to the Health Promotion Board (HPB). I also consent to my child/children being screened under the health programmes of HPB. I understand that HPB will keep my particulars and those of my child/children strictly confidential.
 
FOR OFFICIAL USE ONLY VERIFICATION OF ELIGIBILITY (TO BE COMPLTED BY CHILD CARE CENTRE)
 
Date:
Full Fees Paid:
Fees for Programmed Type:
Net Fees Paid:
Add–Other Charges (transport, uniforms, etc):
Subtract–Discounts (staff, siblings, etc):
Special Approval for subsidy?:
Remarks
I have verified the foregoing information to be true and understand that our centre may be liable to prosecution for any information furnished by the applicant which I know to be false or do not believe to be true. I understand that any part of this application improperly completed may lead to the rejection of the application.
Name/Designation: