MCH Outreach Consent Form

Introduction and consent

The City of Port Phillip Maternal and Child Health (MCH) service is proud to offer Key Age and Stage (KAS) appointments in a childcare setting.

We hope this makes our service easy to access, located in a familiar and safe environment for your child, and done in collaboration with your child's educator if appropriate.

I consent to the MCH nurse completing my child’s KAS (Key Age Stage) appointment at their childcare centre. *

Yes

I consent for the exchange of relevant information between the MCH nurse and childcare educator. *

Yes

I consent for transfer of my child’s health record to City of Port Phillip. *

Yes

Green Book (Child Health Record)

Part of the KAS assessment requires parents to complete a PEDS assessment, which you will find in your child’s green book. Please complete the 10 questions on the page corresponding to your child’s age and send it in to childcare. We will record your child’s growth in the green book for you.

What would you like the MCH nurse to know about your child? Please share any strengths or areas of concern.

Child details

What is your child's name? *

What is your child's date of birth? *

What is the primary address of your child? *

Which childcare centre does your child attend? *

Parent/Guardian Details

What is your name? *

What is your relationship to the child? *

What is your email address? *

What is your best phone number? *

What is your preferred contact method for after the nurse visit? *

PhoneEmail

Would you like to add details of an additional parent or guardian?

What is your name? *

What is your relationship to the child? *

What is your email address? *

What is your best phone number? *

What is your preferred contact method for after the nurse visit? *

PhoneEmail

Would you like to add details of an additional parent or guardian?

What is your name? *

What is your relationship to the child? *

What is your email address? *

What is your best phone number? *

What is your preferred contact method for after the nurse visit? *

PhoneEmail

Would you like to add details of an additional parent or guardian?

What is your name? *

What is your relationship to the child? *

What is your email address? *

What is your best phone number? *

What is your preferred contact method for after the nurse visit? *

PhoneEmail

Would you like to add details of an additional parent or guardian?

What is your name? *

What is your relationship to the child? *

What is your email address? *

What is your best phone number? *

What is your preferred contact method for after the nurse visit? *

PhoneEmail

Data privacy and collection

The personal information requested on this form is being collected by the City of Port Phillip (CoPP) and will be handled in accordance with the Privacy and Data Protection Act 2014. This information will be used solely by the council for that primary purpose or directly related purposes. It will be treated in compliance with the CoPP Information Privacy Policy and the Information Privacy Act.

Yes, I give permission for the City of Port Phillip to store and process my data. *

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