Liste d’attente

This form must be completed by a person with parental responsibility. Parents are responsible for ensuring that all information on the form is correct.

Your Name

Your Email

 I have parental responsibility for the child named bellow, and I will be responsible for paying the fees.
__________________________________________________________________________

YOUR CHILD

First name of child

Family name of child

 Boy Girl

Date of birth

Requested admission date

Requested days
 Monday Tuesday Wednesday Thursday Friday
 OR I am flexible on which days my child attends

__________________________________________________________________________

PARENT / CARER 1

First name

Family name

Parental responsibility  yes no

Telephone (home)

Telephone (mobile)

Telephone (work)

Email

Address

Does the child live at this address?  yes no

Languages spoken at home to your child:

Languages spoken at home in front of your child:

__________________________________________________________________________

PARENT / CARER 2

First name

Family name

Parental responsibility  yes no

Telephone (home)

Telephone (mobile)

Telephone (work)

Email

Address (if different than Parent / carer 1 's address)

Does the child live at this address?  yes no

Languages spoken at home to your child:

Languages spoken at home in front of your child:

__________________________________________________________________________

EMPLOYER / COLLEGE DETAILS

Parent 1 - occupation

Parent 1 - Name and address of Employer / College

Parent 2 - occupation

Parent 2 - Name and address of Employer / College

__________________________________________________________________________

EMERGENCY CONTACTS (authorised to collect your child)

Name of emergency contact

Relationship to child

Telephone

Address

__________________________________________________________________________

How did you hear about us?

Did you visit any other nurseries?

Why did you choose us?

__________________________________________________________________________

MEDICAL INFORMATION

Is attendance at hospital or clinic still necessary? Please give details.

Does your child have any special health or educational needs, e.g. speech therapy?

__________________________________________________________________________

EMERGENCY TREATMENT CONSENT

In events of a medical emergency we will endeavour to contact you using the information you have supplied within this form as parents/carer/guardian and named emergency contacts. If this proves not possible and your child needs emergency medical treatment a member of staff will accompany your child to hospital if necessary. We must therefore have your permission in this respect. Please complete this with your application:

 I hereby give consent for my/our child to receive emergency medical treatment as appropriate in the event of a medical emergency.

Please state below any medical procedures you would not wish your child to have (e.g.
blood transfusion).

__________________________________________________________________________

HOME VISITS

I understand that I can request a home visit from my child’s key worker and Manager before my child begins attending nursery. I further understand that this is not something I must do, but something I can request if I feel it would benefit my child.

 I would like a home visit I would not like a home visit.

IIf you would like a home visit, please telephone the school 2 weeks before your preferred
start date to make an appropriate appointment.

__________________________________________________________________________

REGISTRATION FEE

Please pay £75 to register your child on the waiting list. This is non-refundable and does not guarantee a place.

 

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