Register Your Child

First Name^*

Middle Name

Last Name^*

Preferred Name

Date of Birth^*

Gender^*

Address 1

Address 2

Address 3

Post Code

Ethnicity

First Language

Nationality

Religion

Start Date

Two Year Old Funding Code

Extended Entitlement Code

Sibling Details

First Name^*

Middle Name

Last Name^*

Preferred Name

Date of Birth^*

Gender^*

Ethnicity

First Language

Nationality

Start Date

Parental Details

Parent/Carer 1

Upload Photo

Authorised to Collect:

Yes No

Emergency Contact:

Yes No

Bill Payer:

Yes No

Parental Responsibility:

Yes No

Title

First Name^*

Last Name

Mobile Phone

Home Phone

Primary Email

Relationship

Date Of Birth

Address 1

Address 2

Address 3

Post Code

Employer

Department

Occupation

NI Number

Work Email

Parent/Carer 2

Upload Photo

Authorised to Collect:

Yes No

Emergency Contact:

Yes No

Parental Responsibility:

Yes No

Bill Payer:

Yes No

Title

First Name^*

Last Name

Mobile Phone

Home Phone

Primary Email

Relationship

Date Of Birth

Address 1

Address 2

Address 3

Post Code

Employer

Department

Occupation

NI Number

Work Email

Upload Documents

Medical Details

Illness and Immunisation Record

Illness Immunisations

Calpol:

Yes No

Chicken Pox:

Yes No

Convulsions:

Yes No

Diptheria:

Yes No

Hepatitis A:

Yes No

Hepatitis B:

Yes No

HIB:

Yes No

Measles:

Yes No

Meningitis B:

Yes No

Meningitis C:

Yes No

MMR:

Yes No

Mumps:

Yes No

Plasters:

Yes No

Pneumonia:

Yes No

Polio:

Yes No

Polio 2 Months:

Yes No

Polio 3 Months:

Yes No

Polio 4 Months:

Yes No

Regular Medication:

Yes No

Respiratory Problems:

Yes No

Rotavirus:

Yes No

Rubella:

Yes No

Scarlet Fever:

Yes No

Tetanus:

Yes No

Visual Impairment:

Yes No

Whooping Cough:

Yes No

All Immunisations Up To Date:

Yes No

Doctor's Details

Doctor Name

Doctor Phone

Doctor's Address

Medical Notes / Medication

Health Visitor

Medical Notes

Health Visitor Contact

Health Visitor Address

Health Visitor Notes

Dietary Requirements and Allergies

Dietary Requirements

Allergies

Additional Details

Visual Impairment:

Yes No

Respiratory Problems:

Yes No

Regular Medication:

Yes No

Special Edu. Needs & Disability (SEND):

Yes No

Booking Pattern

Please select your preferred booking pattern.

Monday:

Half Day AM 8-1

full day session 8-6

HALFDAY PM 13.00-18.00

Tuesday:

Half Day AM 8-1

full day session 8-6

HALFDAY PM 13.00-18.00

Wednesday:

Half Day AM 8-1

full day session 8-6

HALFDAY PM 13.00-18.00

Thursday:

Half Day AM 8-1

full day session 8-6

HALFDAY PM 13.00-18.00

Friday:

Half Day AM 8-1

full day session 8-6

HALFDAY PM 13.00-18.00

Don't worry, this will get re-confirmed for each child when you are offered a childcare place.

Permissions

Please let us know any permissions for your child that you are happy with.

General

Administer Calpol

Yes No

Administer First Aid

Yes No

Administer Medication

Yes No

Administer Teething Gel

Yes No

Apply Nappy Cream

Yes No

Apply Sun Cream

Yes No

Authorise Emergency Treatment

Yes No

Authorise Insect Bite Treatment

Yes No

Face Paint

Yes No

Plasters

Yes No

Press Releases

Yes No

Promotional Material

Yes No

Published Content

Yes No

Toothbrushing

Yes No

Outings

Authorise Off Premises Visits

Yes No

Outings On Foot

Yes No

Online and Media

Allow Photos

Yes No

Allow Video

Yes No

Social Media

Yes No

Agreement

Information Security

By clicking "Submit Childcare Registration" you agree to us electronically recording and storing this information. All information is secure and will be encrypted using 256-bit encryption technology.

Accurate Information

You confirm that the information you have provided is both complete and accurate and you understand that the giving of false information could invalidate your childcare contract terms and conditions.

Policies and Procedures

I have been taken through the Nursery policy and procedures by the Nursery Manager and fully comprehend the permissions authorised.

Confirmation and Digital Signature

I confirm I have read the terms and conditions of the Nursery and agree to comply with them and any updated regulations and instructions where necessary.

Permissions Authorised:

Information Security

Accurate Information

Policies and Procedures

Confirmation & Signature

Parent Agreement

23/04/2019

You () agree to the terms and conditions of the Nursery and agree to comply with them and any updated regulations and instructions where necessary.