HOLIDAYCLUB
BOOKING FORM
(Payment to be received with Booking Form) /
CHILD DETAILS
First Names / Surname
Date of Birth
_ _ / _ _ / _ _ _ _ / Age on Booking (4-7yrs only) / Female / Male
P A R E N T / G U A R D I A N D E T A I L S / E M E R G E N C Y C O N T A C T S
Relationship
to Child / Relationship
to Child
First Name / First Name
Surname / Surname
Childs Home Address
Postcode / Home Phone
Mobile Phone
Home Phone / Work Phone
Mobile Phone / A L L E R G Y / D I E T R Y I N F O R M A T I O N
(Please provide details of any medical allergies, food allergies or foods to avoid)
Work Phone
Home Email
(Required to confirm booking)
M E D I C A L C O N D I T I O N S / M E D I C I N E S
(Please provide details of any medicines your child takes regularly)
Work Place/Area
M E D I C A L I N F O R M A T I O N / D I S A B I L I T Y O R A D D I T I O N A L N E E D S
Doctor Name / Physical / Sensory
Surgery Name / Learning
Speech, Language / Behaviour
Surgery Address / Other / Chronic Illness
Surgery Phone / Please provide details
P E R M I S S I O N S
Yes / No / Yes / No
We give permission for my child’s photograph to be taken / We give permission for my child to attend planned outings
In the event of your child requiring emergency aid, we need your authorisation for senior staff to call the emergency services and/or administer emergency first aid or take to the Casualty Dept until you can get to us / We agree that Calpol may be given upon our verbal consent if our child becomes ill
We give permission for sun cream to be administered when necessary
S E S S I O N R E Q U I R E M E N T S
(Please Circle)
Full Day Long (FDL)
8am – 6pm= £25 / Full Day Short (FDS)
8am-4pm = £22 / Morning (AM)
8am – 1pm = £15 / Afternoon (PM)
1.30pm – 6pm = £185
WeeksAvailable / Monday / Tuesday / Wednesday / Thursday / Friday
20th Feb – 24thFeb 2017 / FDL FDS AM PM / FDL FDS AM PM / FDL FDS AM PM / FDL FDS AM PM / FDL FDS AM PM
3rd April – 7th April 2017 / FDL FDS AM PM / FDL FDS AM PM / FDL FDS AM PM / FDL FDS AM PM / FDL FDS AM PM
10th Apr – 13thApril 2017 / FDL FDS AM PM / FDL FDS AM PM / FDL FDS AM PM / FDL FDS AM PM / No Holiday Club
18th Apr – 21st April 2017 / No Holiday Club / FDL FDS AM PM / FDL FDS AM PM / FDL FDS AM PM / FDL FDS AM PM
30th May – 2nd June 17 / No Holiday Club / FDL FDS AM PM / FDL FDS AM PM / FDL FDS AM PM / FDL FDS AM PM
24th July – 28th July 17 / FDL FDS AM PM / FDL FDS AM PM / FDL FDS AM PM / FDL FDS AM PM / FDL FDS AM PM
31st July – 4th Aug 17 / FDL FDS AM PM / FDL FDS AM PM / FDL FDS AM PM / FDL FDS AM PM / FDL FDS AM PM
7th Aug – 11th August 17 / FDL FDS AM PM / FDL FDS AM PM / FDL FDS AM PM / FDL FDS AM PM / FDL FDS AM PM
14th Aug – 18thAugust 17 / FDL FDS AM PM / FDL FDS AM PM / FDL FDS AM PM / FDL FDS AM PM / FDL FDS AM PM
21st Aug – 24th August 17 / FDL FDS AM PM / FDL FDS AM PM / FDL FDS AM PM / FDL FDS AM PM / No Holiday Club
23rd Oct – 27th Oct 17 / FDL FDS AM PM / FDL FDS AM PM / FDL FDS AM PM / FDL FDS AM PM / FDL FDS AM PM
Your requirements for the Little Tots Stone Heath Holiday Club should be listed on this form which must be received at the address below. You will be invoiced via email, so please ensure you supply an email address (clearly written). You will receive confirmation of your booking via email. No credits or refunds can be given for non-attendance.
PLEASE PROVIDE YOUR CHILD WITH A PACKED LUNCH and/or TEA.
Parent / Carer Name (Print) / Parent / Carer Name (Signature) / Date Signed_ _ / _ _ / _ _ _ _
LITTLE TOTS
STONEY HEATH
HOLIDAYCLUB / Please return completed Booking Form
Little Tots Nurseries Ltd
59 Prince of Wales Avenue, Reading, RG30 2UJTel: 0118 959 1371
Email: