Online Application Form

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 Years 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 details and for the safety and well-being of your child.

Key Information

Childs Name:(Required)

Known as:

Date of birth:(Required)

Gender:(Required)

Name of parent(s) with whom the child lives(Required)

Parent 1(Required)

Do you have parental responsibility for this child?(Required)

If no, do you have legal contact?(Required)

Address(Required)

Home Telephone number(Required)

Mobile Telephone number(Required)

Email address(Required)

Parent 2

Do you have parental responsibility for this child?

If no, do you have legal contact?

Address

Home telephone number

Mobile telephone number

Email address

Please provide the names and contact details of 2 people (other than parents/guardians) who we can contact in case of an emergency. Please ensure these people are happy for us to contact them and to hold their details.

1 - Emergency Contact Name(Required)

Home telephone number:(Required)

Mobile telephone number(Required)

Relationship to child(Required)

2 - Emergency Contact Name(Required)

Home telephone number(Required)

Mobile telephone number(Required)

Relationship to the child(Required)

A password system operates in our setting. A secure password is required and will need to be used by emergency contacts and persons authorised to collect your child. Ideally, this should be one word and something that is easily memorable. 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.

My secure password is:(Required)

Persons authorised to collect my child - other adults who may collect your child in your absence. Authorised persons must be over the age of 18.

1st Authorised Person - Name(Required)

Home telephone number(Required)

Mobile telephone number(Required)

Relationship to the child(Required)

2nd Authorised Person - Name(Required)

Home telephone number(Required)

Mobile telephone number(Required)

Relationship to the child(Required)

We have the safety and well-being of the children in mind at all times and we are sure that you will appreciate that persons known to you are strangers to us and we do need means of identifying those you have authorised to collect your child (either authorised or emergency contacts) when you are unable to. We as a setting and especially your child/children key person will be familiar with you, but we do not always have the opportunity to meet both parents. This is also true of your nominated emergency contacts and authorised persons. We therefore request that should anyone unknown to us be collecting your child that you inform us in advance and show us a photograph to enable us to identify him or her when they collect your child.

Health Information

Does your child suffer from any of the following (please tick those which apply)(Required)

If you have ticked any of the boxes above, please give details here:

Does your child require medication, either long term for existing conditions of lifesaving drugs such as Ventolin? (please give details of the medication and dosage)(Required)

Does your child have any special dietary needs or preferences?(Required)

If yes, please give details below.

Does your child have any allergies?(Required)

If yes, please give details below.

Name of GP(Required)

Surgery(Required)

Address(Required)

Telephone(Required)

Safeguarding Children

Does your child have a social worker for any reason?(Required)

Name

Telephone Number

Based at

What is the reason for the involvement of Social Services with your family?

For Office Use – NB If the child has a child protection plan, make a note here, but do not include details. Ensure these are obtained from the social worker named above and keep these securely in the child’s named Child Protection file.

The following information is voluntary, and you do not have to complete it. However, we have a legitimate interest in requesting this data as it will assist in providing the necessary care for your child and allow us to monitor and assess their development.

Health Visitor

Name

Telephone Number

Based at

Has your child had their two-year-old progress check?

If so, on what date was this completed?

Are you able to share this information with this setting?

What is the main language spoken at home?

How would you describe your child’s ethnicity/cultural background?

What is the main religion in your family?

If English is an additional language, will this be your child’s first experience of being in an English-speaking environment?

Are there any festivals or special occasions celebrated in your culture that your child will be taking part in and that you would like to see acknowledged and celebrated while he/she is in our setting?

Special Educational Needs and Disabilities

Does your child have any special needs or disabilities?(Required)

If yes, please give details below?

What (if any) special support will your child require in our setting?

Professionals involved with the child:

Name

Agency

Telephone Number

Role

Name

Agency

Telephone

Role

The following section contains information for which we need your consent. As required by data protection we have a duty to inform you that you can withdraw your consent for any of the permissions detailed below at any time. Should you wish to withdraw consent please discuss this with a member of staff in the first instance.

If emergency treatment is required, either whilst your child is on the premises or on an outing, (for the duration of your child’s time with us) and the parents or legal guardians cannot be reached immediately, your signature in the space provided below empowers the settings management to exercise their own judgement in calling the doctor/dentist indicated above or to transport the child to a hospital casualty department by ambulance. Please read and fill in the declaration below, cross out the statement/wording that does not apply and sign and date this section.

I do give consent on my / our behalf for an anaesthetic to be administered or for any other urgent medical treatment to be given.(Required)

Signatures of parent(s):(Required)

Date(Required)

Permission for the application of sun cream(Required)

I consent to my child participating in off-site outings as part of daily practice e.g., trips to the park, shops etc.(Required)

I consent for my child having their photograph taken for use in displays, for name pegs, etc. within the setting(Required)

I consent to my child having their photograph taken to be used for publicity purposes – website, flyers.(Required)

I consent to my child’s photograph being used on the setting’s social media sites(Required)

I consent to my child’s artwork (with their name) being displayed in the setting(Required)

I consent to my child’s photograph being used in learning journeys of other children within the setting(Required)

I consent to my child being videoed for use by the setting staff only with regards to observational purposes either assessment of children, an activity or for monitoring children’s behaviour(Required)

I consent to the video, as mentioned above, to be shared with other professionals visiting the group such as Early Years Advisors, SENCO, Health Visitor etc. if necessary(Required)

I consent to my child’s learning journey being shared with Ofsted inspectors and/or as part of audits by the local authority(Required)

Please sign below to confirm your consent for the indicated statements above:(Required)

SPECIAL NOTE: Please notify us immediately of any changes to the information provided. Please feel free to come and discuss any problems or concerns with us. If there are any other notes you would like to add, please use the space below.

SPECIAL NOTE:

I/We understand that 4 weeks written notice will be require should I/We decide that we no longer require our child’s place at Nursery and that all fees due will be paid prior to leaving.(Required)

I consent

Signature of Parent (s)/Carer (s)(Required)

Date(Required)

I / We confirm that the information provided on this form is correct to the best of our knowledge. Signature of Parent (s)/Carer (s):(Required)

Date(Required)

Initially places will be awarded on a first come first served basis. Please tick the days and sessions you require below…

Breakfast (7:45-8:45) - £5.50

Monday

Tuesday

Wednesday

Thursday

Friday

Core Session (8:45 – 11:45 AM) - £16.50

Monday

Tuesday

Wednesday

Thursday

Friday

Core Session (11:45 – 2:45 PM) - £16.50

Monday

Tuesday

Wednesday

Thursday

Friday

Extended Afternoon (2:45 – 3:15) - £2.50

Monday

Tuesday

Wednesday

Thursday

Friday

After School Option 1 (3:15 – 4:15) - £5.50

Monday

Tuesday

Wednesday

Thursday

Friday

Options 2, including light tea (3:15 – 5:15) - £13.75

Monday

Tuesday

Wednesday

Thursday

Friday

Option 3, including light tea (3:15 – 6:00) - £16.50

Monday

Tuesday

Wednesday

Thursday

Friday

CAPTCHA

Online Form

Key Information