Application 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 Address

Doctor Telephone Number

Health Visitor

Health Visitor Address

Health Visitor Telephone Number

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*

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*

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*

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*

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)

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.

Application Form

Child’s Details

Allergies

Doctor

Vaccinations

Date of last Tetanus jab

Dietary Requirements

Medication Details

Special Needs

Information regarding Parent/s or Carer/s

Emergency Contact Details

Note: It is your responsibility to ensure these people are happy for us to contact them and to hold their details.

Collection Password

Dock Road Days required

Starting Date Required

Bradleigh Avenue Days required

Starting Date Required

Funding

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