Waiting list Posted on July 14, 2014 by administration 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.