Events

DOB

Gender
MaleFemale

Home address

Postcode

Ethnicity

Other Language spoken

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Parent(s)/Carers Details:

Parent 2 Details

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Details of Emergency Contact

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Medication

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

Allergies

Please let us know of any allergy your child may have or any dietary requirement

Additional Needs

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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