Register Your Child

First Name^*

Middle Name

Last Name^*

Preferred Name

Date of Birth^*

Gender^*

Ethnicity

First Language

Nationality

Start Date

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

Relationship

Date Of Birth

Address 1

Address 2

Address 3

Post Code

Employer

Department

Occupation

NI Number

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

Relationship

Date Of Birth

Address 1

Address 2

Address 3

Post Code

Employer

Department

Occupation

NI Number

Medical Details

Illness and Immunisation Record

Illness Immunised

Illness - Chicken Pox:

Yes No

Illness - Diptheria:

Yes No

Illness - Hepatitis A:

Yes No

Illness - Hepatitis B:

Yes No

Illness - Measles:

Yes No

Illness - Meningitis C:

Yes No

Illness - Mumps:

Yes No

Illness - Pneumonia:

Yes No

Illness - Polio 2 Months:

Yes No

Illness - Polio 3 Months:

Yes No

Illness - Polio 4 Months:

Yes No

Illness - Rubella:

Yes No

Illness - Scarlet Fever:

Yes No

Illness - Tetanus:

Yes No

Illness - Whooping Cough:

Yes No

Illness - Convulsions:

Yes No

Illness - HIB:

Yes No

Illness - Polio:

Yes No

Meningitis B:

Yes No

Illness - Rotavirus:

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.

Administer First Aid:

Yes No

Administer Medication:

Yes No

Administer Calpol:

Yes No

Administer Teething Gel:

Yes No

Authorise Emergency Treatment:

Yes No

Authorise Insect Bite Treatment:

Yes No

Apply Nappy Cream:

Yes No

Apply Sun Cream:

Yes No

Subsidy:

Yes No

Published Content:

Yes No

Face Paint:

Yes No

Press Releases:

Yes No

Promotional Material:

Yes No

Plasters:

Yes No

Child In Nappies:

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

21/11/2018

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