Toy Library Enrolment Form

Toy Library Enrolment Form
Carer Details
Thank you for your interest in participating in a South Eastern Community Connect (SECC) program. SECC has been proudly caring for our community for over 40 years thanks to the support of government funding, grants and fundraising initiatives. Can you spare a moment of your time? Upon registration, you will be prompted to answer a few simple questions. We’d greatly appreciate your time and support in completing the form, as this helps SECC directly report to our funding bodies to demonstrate that our programs are relevant, utilised, and necessary to help assist our local community. Funding ensures we can continue to offer our programs at a heavily subsidised fee - or at no cost at all. Rest assured all information provided is held in the strictest of confidence and is used for funding reporting only, shared only as part of our annual reporting. Additionally, the decision to answer these questions is optional. Thank you again for your interest in our programs, and we look forward to learning, growing, and thriving together as a community.
Title*
Relationship Status*
Name*

First NameLast Name
Gender*
Relationship to child*

DadMumGrandparentOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
Home Phone

Area CodePhone Number
Mobile number*
Parent's date of birth*

DayMonthYear
Do you identify as Aboriginal or Torres Strait Islander?*
Country of birth*
Main language/s spoken at home*
What is your household composition?*

Single (person living alone)Sole parent with dependent(s)CoupleCouple with dependent(s)Group of related adultsGroup of unrelated adultsHomeless / no householdOther
GP's name and contact details
Do YOU have a disability, impairment or condition that we need to be aware of? Tick all that apply.*

Intellectual/learningPsychiatricSensory/speechPhysical/diverseMedical or health (e.g. asthma)No
If you answered yes to any of the above, please specify:
Do you use any of the following mobility aids? Tick all that apply.*

CrutchesWalking FrameWalking StickWheelchairNoOther
Have you had a fall in the last 6 months?*

YesNo
Have you experienced any of the following in the past?*

Heart conditionRespiratory conditionEpilepsyFainting or dizzinessHead injuries of any kindOther physical or cognitive disabilities that might affect your ability to participateNo
If you answered yes to any of the above, please specify:
Highest level of education?*
Employment status?*
Main source of income?*
Income frequency
Approximate Gross Income (whole dollars only)
How did you hear about our Toy Library? (tick all that apply)*

A family member told meA friend told meWalking past the SECC Hub on Botany RdThe SECC WebsiteA SECC email newsletterA SECC printed newsletterA Facebook postA Facebook eventA Facebook group (such as South Eastern Sydney Playgroups)An Instagram postA flyer/brochure about SECCA poster on a noticeboardA GP or hospital referralAn Allied Health referral (e.g. Social Worker, Occupational Therapist)A community services agency or community centre (e.g. JNC, The Deli)My Aged CareAn NDIS referralA Humanitarian Settlement Program referralEducational agency (e.g. School, TAFE)Other
Emergency Contact / 2nd Parent/Guardian
Name*
Second Parent/Gaurdian date of birth*

DayMonthYear
Mobile number (NOT yours)*
Relationship to child*
Children's Details
Child 1: Full Name*
Gender*
Date of Birth*

DayMonthYear
Date
Does your child identify as Aboriginal or Torres Strait Islander?
Does your child have a disability, impairment or condition that we need to be aware of? Tick all that apply.*

Intellectual/learningPsychiatricSensory/speechPhysical/diverseMedical or health (e.g. asthma)No
If you answered yes to any of the above, please describe:
Does your child have any allergies or anaphylaxes?*

YesNo
If you answered yes, please describe:
Child 2: Full Name
Gender
Date of Birth

DayMonthYear
Date
Does your child identify as Aboriginal or Torres Strait Islander?
Does your child have a disability, impairment or condition that we need to be aware of? Tick all that apply.

Intellectual/learningPsychiatricSensory/speechPhysical/diverseMedical or health (e.g. asthma)
If you answered yes to any of the above, please describe:
Does your child have any allergies or anaphylaxes?

YesNo
If you answered yes, please describe:
Child 3: Full Name
Gender
Date of Birth

DayMonthYear
Date
Does your child identify as Aboriginal or Torres Strait Islander?
Does your child have a disability, impairment or condition that we need to be aware of? Tick all that apply.

Intellectual/learningPsychiatricSensory/speechPhysical/diverseMedical or health (e.g. asthma)
If you answered yes to any of the above, please describe:
Does your child have any allergies or anaphylaxes?

YesNo
If you answered yes, please describe:
Child 4: Full Name
Date of Birth

DayMonthYear
Date
Gender*
Does your child have a disability, impairment or condition that we need to be aware of? Tick all that apply.

Intellectual/learningPsychiatricSensory/speechPhysical/diverseN/A
Does your child have any medical condition (eg Asthma) that we need to be aware of? If yes, please describe.
Multimedia Consent
South Eastern Community Connect (SECC) may take photography, audio, and video recording throughout the duration of its programs and activities for multimedia content production which is typically used in organisational promotion and marketing in a range of platforms and mediums. Do you provide multimedia consent?
No, I do not provide multimedia consentYes, I, as named above, consent to South Eastern Community connect and its agents (including without limitation, any photographer, interviewer, creative agency or media organisation) recording images of me during SECC events, programs and activities for promotional purposes. I consent to these images being used and disclosed to any person or organisation approved by South Eastern Community Connect, including without limitation, by publishing them as part of a book, poster, brochure or report, newspaper advertisement or article television advertisement or program, radio advertisement or program and including on the world wide web or any other social media. I agree that South Eastern Community Connect and its agents may edit the images prior to publication, as they consider appropriate, without first consulting me.
Privacy and Confidentiality Policy:
SECC has a strict policy around issues of privacy and confidentiality. All files are securely maintained.Your name and personal details will not be given to any person or agency outside of the Centre without your informed and voluntary consent. Exceptions to this agreement involve:
- Where a child or young person under the age of 16 years is at risk of significant harm from abuse or neglect (e.g. a child or young person witnessing incidents of Domestic Violence)
- Where there is a serious and imminent threat to life and health of any person, including the person seeking a service (e.g. a person is at risk of hurting themselves or harming others)
- Where a person discloses information that would substantially assist in the prosecution of any offence punishable by 5 or moreyears imprisonment
- Where a worker is required to provide documents (e.g. a person's file) or give evidence under subpoena
If you have any questions please ask a staff member- all SECC staff can describe these exceptions in more detail.
Data Collection
SECC collects basic program statistics. The collection is for funding and reporting purposes. The collection never identifies individuals. The collection allows us to monitor service usage patterns across the years. It also allows us to report to our Board and the bodies that provide us with funding with service provision. At no stage is any identifying data provided to either the Board of SECC or to funding bodies. If you choose to not have this particular information passed on you are able to inform the worker. You will still be able to receive services from SECC. Do you consent to the collection of statistics for the purposes stated above on the condition that any collection will not identify you personally?
YesNo
Would you like us to keep you informed about upcoming events and programs in Mascot?*
Conditions of Borrowing

The borrower is responsible to ensure that items borrowed are suitable for the age and skills of the children who will use them. The Toy Library shall not be liable for any injury, in any way.

The Toy Library cannot accept any liability as a result of a failure to comply with specific instructions, and under no circumstances will the Toy Library be held liable for any injury caused by or arising from items supplied.

The borrower must ensure that any or all children or person using any equipment supplied by the Toy Library are supervised at all times. It is the borrower’s responsibility to examine the supplied items prior to use to determine fitness and state of repair. The borrower shall be responsible for any indemnity against loss or damage. In the event of a loss, damage or theft of the item/s supplied the borrower must replace the item. All items are to be returned in the same condition as borrowed.

If your child is suffering from a communicable disease, please do not borrow toys until they are well. If your child has an infectious disease, whilst toys are on loan please disinfect them prior to returning them and let the Toy Librarian know.

Toys are to be cleaned prior to returning and returned with all parts, including tags and bags.

Most toys have rechargeable batteries and must be returned with rechargeable batteries in these cases. A $4 fee per lost rechargeable battery will be applied if not replaced.

Late fees are $1 per toy per weekday. If you wish to extend your loan you must notify the Toy Librarian prior to the toy being late. Extensions will be permitted where possible.

Failure to comply may result in a suspension or termination of your membership.

Terms are subject to change. In such an event 14 business days notice will be given in writing.
I have read and agree to the conditions of borrowing.*

YesNo
Signature

Clear
How to buy your Annual Membership $40

Option 1.

Pay in person (Cash or Card) at the SECC Hub in Mascot

1007 Botany Road Mascot

Option 2.

Bank Transfer

Account Name: South Eastern Community Connect

(BSB) 062239

(Account Number) 10182171

and mark the payment ‘Toy Library Membership’.

Thank you.

Enquiries: 0416 150 532
Should be Empty:

Toy Library Enrolment Form

Carer Details

Emergency Contact / 2nd Parent/Guardian

Children's Details

Multimedia Consent

Privacy and Confidentiality Policy:

Data Collection