Pre School in Grays
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Application Form
Little Roos
About Us
Application Form
Go to the
Parents Consent Form
.
Child’s Details
We need some details about your child and family. We have a legal obligation to collect and process this information in Accordance with The Early Year Foundation Stage (Welfare requirements) Regulations 2012 and therefore we do not require your consent for the first section of this form. Where information to be supplied is voluntary or where we do need consent this is identified. The information provided will be kept in paper form and used for the purpose of maintaining appropriate contact.
TO CLAIM NURSERY EDUCATION FUNDING THE FIRST TERM AFTER YOUR CHILD’S 3RD BIRTHDAY WE ARE REQUIRED TO SEE THEIR ORIGINAL BIRTH CERTIFICATE
Main Emergency Contact Number:
*
Childs Name
*
First Name
Last Name
Date of Birth
*
Gender
*
Male
Female
Address
*
Post Code
*
Allergies
Allergy
Allergy Details
Allergy
Allergy Details
Doctor
Doctor
Doctor Address
Doctor Telephone Number
Health Visitor
Health Visitor Address
Health Visitor Telephone Number
Vaccinations
Select Vaccinations
Diphtheria
Whooping Cough
Polio
Measles
Tetanus
Mumps
Rubella
Hib. Meningitis
Meningitis C/D
Date of last Tetanus jab
Select the date of last Tetanus jab
Dietary Requirements
Select Dietary Requirements
None
No milk
No eggs
Vegetarian
Other
Other Dietary Requirements
Medication Details
Please give details of any medication your child takes
Special Needs
Please give details if your child has special needs, including medical needs
Information regarding Parent/s or Carer/s
Parent/s or Carer/s Name
*
Please select
Mr
Mrs
Ms
Miss
Dr
Prefix
First
Last
Parental Responsibility
*
Yes
No
Relationship to Child
*
Home Telephone Number
Work Telephone Number
Mobile Telephone Number
Parent/s or Carer/s Address
*
Email Address
*
Second Parent/s or Carer/s
Yes
No
Parent/s or Carer/s Name
*
Please select
Mr
Mrs
Ms
Miss
Dr
Prefix
First
Last
Parental Responsibility
*
Yes
No
Relationship to Child
*
Home Telephone Number
Work Telephone Number
Mobile Telephone Number
Parent/s or Carer/s Address
*
Email Address
*
Emergency Contact Details
Please provide the names and contact details of 2 people (other than parents/guardians) who we can contact in case of an emergency. Persons authorised to collect the child. This is any other adult who may collect your child in your absence. Authorised persons must be over 18 years of age.
Emergency Contact #1 Name
*
Please select
Mr
Mrs
Ms
Miss
Dr
Prefix
First
Last
Relationship to Child
*
Home Telephone Number
Work Telephone Number
Mobile Telephone Number
Parent/s or Carer/s Address
*
Emergency Contact #2 Name
*
Please select
Mr
Mrs
Ms
Miss
Dr
Prefix
First
Last
Relationship to Child
*
Home Telephone Number
Work Telephone Number
Mobile Telephone Number
Parent/s or Carer/s Address
*
Note: It is your responsibility to ensure these people are happy for us to contact them and to hold their details.
Collection Password
A password system operates in our setting. A secure password is required and should be used by emergency contacts and persons authorised to collect you child. Ideally this should be one word and something that is easy to remember. Please do not use obvious things such as middle names. The password is required from anyone collecting your child. If they do not have the password we will not release your child to them.
Collection Password
*
Dock Road Days required
(Please tick which sessions you require)
Monday
Monday Times
9.30am - 12.30pm
9.30am-3.30pm
12.30pm - 3.30pm
Tuesday
Tuesday Times
9.30am - 12.30pm
Wednesday
Wednesday Times
9.30am - 12.30pm
9.30am-3.30pm
12.30pm - 3.30pm
Thursday
Thursday Times
9.30am - 12.30pm
9.30am-3.30pm
12.30pm - 3.30pm
Friday
Friday Times
9.30am - 12.30pm
Starting Date Required
Select the starting date required
Bradleigh Avenue Days required
(Please tick which sessions you require)
Monday
Monday Times
8.30am-1pm
8.30am-11.30pm
9am-12pm
12.30am-3.30pm
1pm-4pm
8.30am-4pm
Tuesday
Tuesday Times
8.30am-1pm
8.30am-11.30pm
9am-12pm
12.30am-3.30pm
1pm-4pm
8.30am-4pm
Wednesday
Wednesday Times
8.30am-1pm
8.30am-11.30pm
9am-12pm
12.30am-3.30pm
1pm-4pm
8.30am-4pm
Thursday
Thursday Times
8.30am-1pm
8.30am-11.30pm
9am-12pm
12.30am-3.30pm
1pm-4pm
8.30am-4pm
Friday
Friday Times
8.30am-1pm
8.30am-11.30pm
9am-12pm
12.30am-3.30pm
1pm-4pm
8.30am-4pm
Starting Date Required
Select the starting date required
Funding
Select the type of funding you receive
2 year
3 year
2 year funding reference
*
Birth Certificate Number
*
3 year funding reference
*
Birth Certificate Number
*
Cultural celebrations
Religious faiths practiced
Other languages spoken at home
Family country of origin
Confirmation
*
have read and understood the information contained in the prospectus and the terms and conditions of Little Roo’s and agreed to wholly abide by them
View the
Terms and Conditions
.
View the
Prospectus
.
*Please Note: NO alterations can be made to this application form without the WRITTEN authorisation of the above signatories.
We do not have the right to withhold information from either parent without written evidence of legal intervention.
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