REGISTRATION FORM

A: DETAILS & HISTORY OF CHILD
Surname: / First Names:
Known as: / Date of Birth:
Sex: / Religion:
Nationality: / First Language:
DOCTOR / Name: / Tel No:
Address:
Road, Nunhead.
MEDICAL
HISTORY / INFECTIOUS DISEASES:
Please advise if your child has been vaccinated against the following:
Tetanus: YES / NO Diphtheria: YES / NO
Chicken Pox: YES / NO Whooping Cough: YES / NO
Poliomyelitis: YES / NO MMR: YES / NO
HIB (Meningitis): YES / NO
Has your child had any infectious illnesses? If so please provide dates and details:
KNOWN ALLERGIES / SENSITIVITIES: Please provide details:
FOOD / Food preferences:
Food dislikes:
Food intolerances / sensitivities:
Foodstuffs forbidden by religion or culture:
SPECIAL RELIGIOUS OR CULTURAL NEEDS
OTHER
SPECIAL NEEDS
B: DETAILS OF PARENT / GUARDIAN / CARER
PARENT / CARER
1 / Name: / Tel No:
Address:
Email Address:
Workplace Tel No: / Email
PARENT / CARER
2 / Name: / Tel No:
Address:
Email Address:
Workplace Tel No: / Email
C: EMERGENCY CONTACT NUMBERS (other than Parent / Guardian / Carer)
CONTACT
1 / Name: / Tel No:
Relationship to Child:
CONTACT
2 / Name: / Tel No:
Relationship to Child:
D: CHILD CARE SESSIONS REQUIRED (please place times into relevant box) min stay 5hrs
Start Date: / Monday / Tuesday / Wednesday / Thursday / Friday
(Child 1)
.
E: DECLARATION
I have read and agree to the Terms and Conditions for Nursery placement for my child. I enclose a cheque ( made payable to Old station nursery for £ ___ in respect of the non refundable Registration Fee.( £30.00 part time place / £45.00 full time place)
Signature: ______Name : (PRINT): ______Date: ______

DECLARATIONS OF CONSENT

Child: / Date of Birth:
Name of Parent / Guardian / Carer:

To ensure that the well-being of the children in our care is safeguarded, we have strict policies covering certain aspects of child care. It would therefore be helpful if you would sign and date each section below in the spaces provided that will give us appropriate authorisations. This Form will be kept in a prominent position in your child’s file. Thank you for your co-operation.

A: MEDICATION & MEDICAL HELP
1. In the event of my / our child requiring a course of prescribed medication, I / we undertake to authorise this through the use of the Nursery’s individual Medication Slip(s), as appropriate:
2. In the event of an accident, or my / our child requiring emergency medical treatment, I / we consent to a member of the Nursery staff to take the child to a GP, or hospital, as needed after being informed: / Signature: ______Date: ______
Signature: ______Date: ______
B: TRIPS & OUTINGS
I / we give consent to my / our child being taken out of the Nursery on day trips and outings, after being informed and on completion of a consent outing form:
Signature: ______Date: ______
C: DROP-OFF & COLLECTION
The following people are authorised to drop my / our child off at the Nursery, and to collect him / her at the end of the Nursery session:
1. Name: ______Relation to child: ______
2. Name: ______Relation to child: ______
3. Name: ______Relation to child: ______
4. Name: ______Relation to child: ______
D: HUMAN RIGHTS
1. I / we understand that, on occasions, the activity programs in the Nursery may involve my / our child’s face being painted. I / we give our consent to this:
Signature: ______Date: ______
2. I / we give our consent to my / our child to be photographed (will strictly be used in his/her observation file) Yes/No, or recorded
(if other parents are filming there child’s birthday in the Nursery) Yes/No :
Signature: ______Date: ______