Emergency Contact Details (Please Give Two)

Enrolment Form 2017

Name Of Child:
Date of Birth: / Expected D of B:
Parents Name: (Mother)
Parents Name: (Father)
Home Address:
Postcode:
Telephone Number: (Mother) Mobile:
Email:
Telephone Number: (Father) Mobile:
Email:
Workplace Contact:
Mother:
Father:

Emergency Contact Details (Please give two)

Name: / Name:
Relationship to Child: / Relationship to Child:
Address: / Address:
Postcode: / Postcode:
Telephone: / Telephone:
Mobile: / Mobile:

Medical Information

Doctor’s Name: / Health Visitor Name:
Address: / Address:
Postcode: / Postcode:
Telephone: / Telephone:
Dietary Requirements:
Long Term Medication
Is your child on any long term medication we should be made aware of?
Allergies
Other
Is there any other information related to the care of your child of which we should be aware
Nappy Size:
Cream Type:
Collection Arrangements
Who is authorised to collect your child other than parents? Your child will only be allowed to leave Nursery with people listed here. Any changes to this information should be made in writing to your Nursery Manager.
Name : / Relationship to child:
Name : / Relationship to child:
Name : / Relationship to child:
As an extra precaution you may use a password. Anyone collecting your child should be made aware of this.
Password:

Placement Required

Start Date Preferred:
Monday / Tuesday / Wednesday / Thursday / Friday
A.M.
P.M.
Full Day
Breakfast Club
After School Club
Deposit Paid: £ / Fees Charges: £
Registration Paid - £50 (non – refundable) YES / NO
Permissions – Do you give the nursery permission to:
Do you give the nursery permission to take photographs of your child for development files : / Yes / No
Do you give the nursery permission to use photographs for promotional purposes? / Yes / No
Do you give the nursery permission to take your child on outings to local shops etc.? / Yes / No
Do you give the nursery permission to administer first aid? / Yes / No
Do you give the nursery permission to take your child to hospital? / Yes / No
I consent to any necessary or emergency treatment to be sought and administered, including anaesthetic and blood transfusions, as considered necessary by the medical authorities. / Yes / No
Do you give the nursery permission to apply high factor sun cream which is provided by yourself / Yes / No
Do you give the nursery permission to apply nappy cream which is provided by yourself / Yes / No
Do you give the nursery permission to allow your child to sleep in a pram or bouncy chair / Yes / No
Signature: / Date:

I have received a copy of the terms & conditions, and I agree to accept them.

I have read policies & procedures available in the main entrance hall and I agree to accept them.

Signature of Parent / Guardian: / Date:
Signature of Parent / Guardian: / Date:
Signature Manager: / Date: