KEEP FOR TWO YEARS (OFSTED GUIDE)

COPIES OF THIS FORM MUST BE KEPT ON THE PREMISES AT ALL TIMES

Playscheme Registration Document-Please complete in blue or black ink.

Details of the Child

Full Legal Name of ChildMale/Female (please delete)

Address

POSTCODE

Date of Birth Position in Family

Preferred Name/Known as Religion

Any known special dietary requirements/Food Allergies

Any known Medical Conditions or allergies to Medication

Any known special needs or other important information

Doctor’s Details : NAME

Address of Surgery

Name of Health Visitor

Name of Parent/Main Carer Signature

Date:

Plaster application - Permission

I do/do not give permission for Staff to apply a hypo-allergenic self adhesive plaster to minor cuts and grazes, should my child need it.

Signed by Parent/Guardian:Date:

To be completed by staff: Information reviewed with Parent/Carer.

Signed by:Position:

Parent Contact Details - Please print in black or blue ink.

Full name of ChildDate of Birth: __/__/____

Parent/Guardian 1Parent/Guardian 2

Name: / Name:
Address: / Address:
Postcode: / Postcode:

Telephone Numbers (Please mark main daytime number for each parent with a *)

Home: / Home:
Work: / Work:
Mobile: / Mobile:
Other: / Other:

Is Parent 1 a legal guardian of this child? Yes/NoIs Parent 2 a legal guardian of this child? Yes/No

(Please delete as appropriate)

Emergency Contact (should Parents be unavailable)

Name:
Address:
Postcode:
Relationship to Child:

Telephone Numbers (Please mark main daytime number with a*)

Home:
Work:
Mobile:
Other:

I/we confirm that the information given on this record is complete. I/we agree that should the information given on this record change, we will provide PaddocksPre-School with the updated information as soon as possible.

I/we agree that PaddocksPre-School may contact the person listed above in the event of emergency where we (the parents/guardians) cannot be contacted, and that this person is authorised to make any necessary decisions in our absence. This person knows that we have given their information to PaddocksPre-School and understands the responsibility involved.

Signed:(Parent/Guardian 1)Date:

Signed:(Parent/Guardian 2)Date:

Signed on behalf of Paddocks Preschool:Date:

Position:

Parental Permission – Emergency Treatment

Please print in black or blue ink.

Full Name of ChildDate of Birth: __/__/____

In order for staff to ensure that your child receives the best and most appropriate care attention and treatment should there be an emergency in the Pre-School, or while on an authorised outing, you need to complete, sign and date the declaration below.

Please complete, sign and date the following declaration.

Declaration for emergencies

I agree to Paddocks Staff taking the necessary steps to ensure that my child______(name of child) receives the best and most appropriate care attention and treatment should there be an emergency or accident in the Pre-School or while my child is on an authorised outing. I give my permission for First Aiders at the Pre-school to administer First Aid Treatment. I understand that Paddocks Staff will make every effort to inform me of any emergency or accident as soon as possible after the event but that they may have to accompany my child______(name of child) to hospital in the case of a serious accident in my absence. I also give my permission for Paddocks Staff to authorise hospital staff to administer essential treatment until my arrival.

Signed by:(Parent/Guardian 1)Date:

Signed by:(Parent/Guardian 2)Date:

If you do not agree with any or all of the above declaration, please do not sign it but make your views known in the space below. The Paddocks Staff will then discuss this with you and do their best to accommodate your particular wishes.

Alternative Arrangements

I do not agree with the above declaration and would prefer the following procedure to be followed for my child______(name of child) in the event of an emergency.

Signed by:(Parent/Guardian 1)Date:

Signed by:(Parent/Guardian 2)Date:

Signed on behalf of PaddocksPre-School:Date:

Position: