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Application Form
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First Name
Last Name
Date of Birth
Gender
Male
Female
Birth Place
Religious Denomination
Name of all Parents or Guardians
Address
Post Code
Email Address
*
Who has Parental responsibility for this child?
Father and Mother
Father only
Mother only
Other
Other (please specify)
Is your child a LAC?
Yes
No
Is your child on a Care Plan?
Yes
No
If yes can you please give the name and contact details of your Social worker
Where one parent or other carers are specified, are these restrictions legally binding and can you provide copies of documentation/evidence?
Occupation of Father
Occupation of Mother
Ethnicity
Child’s First Language
Home Language
Telephone number(s) Father (Home)
Telephone number(s) Father (Work)
Telephone number(s) Mother (Home)
Telephone number(s) Mother (Work)
Emergency Contact - 1
Emergency Contact - 2
Relation to child
Please write down a ‘PASSWORD’ to be used when child is collected by any other person other than Mum or Dad (i.e. memorable place or name)
Any special dietary requirements? i.e. No beef etc
Proposed date of entry and age of child
Days Required (please check)
Monday
Tuesday
Wednesday
Thursday
Friday
Date of Application
Name of Child
Date of Birth
Doctor’s Name
*
Doctor's Address
Doctor’s Phone Number
Postcode
Health Visitor’s Name
*
Health Visitor’s Phone Number
Have they any special health problems/allergies which the nursery should be aware of?
Any special medication/treatment required?
Immunisation Details
I hereby give consent to staff to administer sun cream supplied from home to my child when required.
Yes
No
I hereby consent to my child being administered Calpol when required.
Yes
No
I hereby understand that in the event of my child being prescribed antibiotics they will not be allowed to attend nursery for the first 48 hours
Yes
No
I hereby understand that my child cannot be given medication containing aspirin whilst in nursery unless prescribed by a Doctor
Yes
No
My child has an allergy to plasters
Yes
No
I give permission for Smart Start Day Nursery to seek any emergency medical advice or treatment necessary.
Yes
No
I hereby give permission for staff to transport my child to hospital in the event of an accident or emergency if the parent/ carer cannot be contacted.
Yes
No
Please give further details below if necessary.
Submit
