Supported Playgroup/ Parent Information Sessions Enrolment Form

Supported Playgroup/ Parent Information Sessions Enrolment Form
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 46 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.
Which group/s are you interested in?*

Mondays: Nature Play, MaroubraTuesdays: Eastlakes Public SchoolWednesdays: Kensington Park Community CentreThursdays: Tote Park, ZetlandFridays: Messy Play, The SECC Community Hub: 1007 Botany Rd, MascotCPR and First Aid for Babies and ToddlersNo Scaredy Cats (Tackling Childhood Anxiety)123 Magic and Emotion Coaching for ParentsSpeech Milestones Sessions for ParentsToy LibrarySchool Holiday Programs at The SECC Community Hub
Parent or Carer Details
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 date of birth*

DayMonthYear
Do you identify as Aboriginal or Torres Strait Islander?*
Country of birth*
Main language/s spoken at home*
How would you describe the makeup of your household?*

Single (person living alone)Sole parent with dependant(s)CoupleCouple with dependant(s)Group of related adultsGroup of unrelated adultsHomeless / no householdOther
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)None
If you answered yes to any of the above, please specify:
Do you use any of the following mobility aids?*

CrutchesWalking frameWalking stickWheelchairNoOther
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 participateNoneOther
If you answered yes to any of the above, please specify:
GP's name and contact details
Highest Level of Education/Qualification*
Employment Status*
Main Source of Income
Income Frequency
Approximate Gross Income (whole dollars only)
ex: 23
Please select your main reason(s) for accessing our services. (Please select reasons that best describe your circumstances and needs. Speak to our staff if you're not sure)*

Physical healthMental health, wellbeing and self-carePersonal and family safetyFinancial resilience (e.g. difficulty finding money in emergencies)EmploymentEducation and skills trainingAge-appropriate development (e.g. support with child's development)Community participation and networks (e.g. want to engage with the community more, feeling socially isolated)Family functioning (e.g. family conflict, needing support with family relationships)Material wellbeing and basic necessities (e.g. limited access to basic resources, food, clothes)Housing
How did you hear about our playgroups? (tick any that apply)*

Walking past the SECC Hub on Botany RdA family member told meA friend told meThe SECC WebsiteA SECC email newsletterA SECC printed newsletter for FamiliesA Facebook postA Facebook eventA Facebook group (such as South Eastern Sydney Playgroups)An Instagram postA flyer/brochureA poster on a noticeboardA GP or hospital referralAllied 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 referralAn educational agency (e.g. school, TAFE)Other
Emergency Contact
Name*
Mobile number (NOT yours)*
Relationship to child*
Children's Details
Child 1: Last Name*
Child 1: First 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)None
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:
Is your child's immunisations up to date?*

YesNo
Child 2: Last Name
Child 2: First 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)None
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:
Is your child's immunisations up to date?

YesNo
Child 3: Last Name
Child 3: First 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)None
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:
Is your child's immunisations up to date?

YesNo
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.
Are your children's immunisations up to date?*

YesNo
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 information you provide on this form includes your personal information. Your personal information is protected by law, including by the Commonwealth Privacy Act.

We are using an IT system called the ‘Data Exchange’ to store your information. This system is hosted by the Australian Government Department of Social Services (DSS). The personal information that is stored on the Data Exchange is only disclosed to us for the purpose of managing your case.

You do not have to consent to sharing your personal information with DSS. If you do not consent to us sharing your personal information, it will not affect the services you receive. If you do consent to sharing your personal information with DSS, you can ask for this information to be removed at any time.

DSS de-identifies your data. This means they remove information that identifies you or that could be used to re-identify you (e.g. your name).

DSS combine your data with other clients’ data in the Data Exchange to identify trends at the program level. This information is used to develop policy, administer grants programs, and conduct research and evaluations.

DSS may use this data to produce reports. These reports may be shared with other organisations. The data in these reports is de-identified.

You can find more information about how DSS will manage your personal information in the DSS privacy policy on their website: https://www.dss.gov.au/privacy-policy. This policy explains:
• how to access the personal information that is stored about you on the Data Exchange
• how you can ask for this information to be changed or removed.
• the circumstances in which DSS may disclose personal information to overseas recipients
• how to complain about a breach of the Australian Privacy Principles by DSS, and how DSS will deal with your complaint.
I consent for my personal information to be stored in the Data Exchange*

YesNo
I consent to participate in follow up research, surveys or evaluation*

YesNo

	I feel very isolated. I have very little contact with friends, family or people in the community. I have no support	I feel fairly isolated. I have little contact with friends, family, or people in the community. I have little support	I feel somewhat connected. I have some contact with friends, family, or people in the community. I have some support	I feel fairly connected. I have a reasonable amount of contact with friends, family, or people in the community. I have pretty good support	I feel very connected. I have a lot of contact with friends or family, or people in the community. I have great support
Community participation & networks

	Compared to other children the same age, my child struggles to master skills or knowledge other children know	Compared to other children the same age, my child can master some skills or knowledge. They are showing signs of learning more	Compared to other children the same age, my child knows many of the same skills and knowledge. My child has learnt some things and their independence and well-being is improving	Compared to other children the same age, my child has mastered most of the skills and knowledge others know, and is improving their independence and well-being	Compared to other children the same age, my child’s skills and knowledge is well developed and helps them to be independent and have good well-being
Age-appropriate development (for parents of children)

	I have a lot of difficulty engaging and working with services to help me improve my circumstances	I have some of difficulty engaging and working with services to help me improve my circumstances	I occasionally have difficulty engaging and working with services to help me improve my circumstances	I seldom have difficulty engaging and working with services to help me improve my circumstances	It is easy to work with services to help me improve my circumstances. I rarely have difficulties
Engagement with relevant support services

	I have no confidence to make decisions that improve my circumstances. This lack of confidence has profound negative impacts	I have limited confidence and limited power to make decision that improve my circumstances. This lack of confidence and choice has negative impacts	I have some confidence and some control in making decisions that improve my circumstances. At times a lack of confidence and choice has a negative impact	Most of the time I have high confidence and feel better empowered to make decisions that improve my circumstances. A lack of confidence rarely has negative impacts	I have very good confidence and feel empowered to make decisions that improve my circumstances
Empowerment, choice & control to make own decisions

Would you like to receive information about upcoming events and programs?*
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Supported Playgroup/ Parent Information Sessions Enrolment Form

Parent or Carer Details

Emergency Contact

Children's Details

Multimedia Consent

Privacy and Confidentiality Policy:

Data Collection