Please complete this form and return it.
The person completing this form must be someone with parental responsibility
DOB
Gender MaleFemale
Home address
Postcode
Ethnicity
Other Language spoken
Please see our medication policy. We will only administer Calpol for temperatures or medication which is ongoing i.e. Asthma pumps. Does your child require any medication? Please specify
Please let us know of any allergy your child may have or any dietary requirement
Please state if you feel your child requires any additional need of support
Is there any special need statement agreement between social services and yourself. (If yes, please confirm that you agree for us to have a copy of the statement on the child’s title to enable us continue, monitoring the needs in the statement if needed
Does your child receive the free school meal
What school do they attend presently
Date you want your child to start the Holiday club MondayTuesdayWednesdayThursdayFriday
Please sign below that you are willing to give your consent for Child’s participation in centre’s outingsHolding personal information (paper and computer based)Sharing information with other professionals, e.g., Health Visitor or Speech therapistPhotography to be used in-house only, e.g., photo observations for child’s folderPhotography to be used in nursery publicity material, including on the internet (children’s nameswill NOT be used on any website or in any publicity)First aid and emergency medical treatment, including the administration of Calpol should your child’stemperature rise suddenly above 37.5°CUse of child’s own provided sun cream or a named brand supplied by the nurseryUse of plasters
I give my permission for my child to partake in the following activities (please tick) All activities are closely supervised Off-site tripsStream walkingTree climbingWoodworkFishingFace paintYogaNail varnishCraftsCookingFire pitSwimming
I have read and agree to the terms and conditions.
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