Buckingham Primary School

Activ-8 Childcare Provision Registration Form

Childs full name______

Date of birth______Age______

Home Address______

______

Telephone number ______

Parents name ______

Parents Daytime contact telephone number and address ______

______

Two emergency contact telephone numbers ______

______

Name of school ______

Doctor’s name and telephone number______

Care/Social worker name and telephone number______

______

Any known medical conditions / allergies / special needs? ______

______

Is your child on prescribed medication? ______

______

In case of serious injury, your child will be taken by ambulance to the nearest casualty department and parents informed as soon as possible.

Do you object to this? YES  NO 

If YES what action do you wish to be taken? ______

______

In case of minor injury your child will be given First Aid by a trained First Aider and parents will be informed when they collect their child.

Do you object to this? YES  NO 

If YES what action do you wish to be taken? ______

______

Snack meals may be provided (Squash, toast, biscuits, fruit etc)

Is there anything you do NOT wish your child to eat? YES  NO 

If yes please specify ______

______

Photographs and video footage may be taken during session time, these may be used in promotional material for the club / school.

Do you give your permission for your child’s image to be used in this way?

YES  NO 

We may show a selected PG rated movie, do you give your child permission to watch?

YES  NO 

We may have water play (pool, slide, sprinkler) do you give your permission for your child to participate.

YES  NO 

You must make arrangements for your child to be collected or to go home by themselves at the end of the booked session. There will be a charge made for late collection.

Please list names of people who are allowed to collect your child (and inform us on the day if anyone not listed is going to collect them)

______

Is your child allowed to go home alone? YES  NO 

(Please note: we are not responsible for children once they leave the site)

Our responsibility is only towards those children who are booked in with us for a session.

The purpose of this form is to collect data for processing within the Activ-8 system. Your signature on this form implies your consent for Activ-8 to process the data. The data will be processed in accordance with the purposes notified by Activ-8 to the Data protection Commissioner’s office and is subject to the Data protection Act 1998. The information given will be entered onto a computer and will form part of Activ-8’s database. Some of the data may be used to promote the interests of Activ-8, i.e. Activ-8 literature/website etc. if you have any objections to this please tick this box 

I have read and agree to the ACTIV-8 childcare provision rules and policies.

Signed______Date ______