Application Form

Name *

First

Last

DOB/EDD

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 (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) Father (Work)

Emergency Contact - 1

Contact number

Relation to child

Emergency Contact - 2

Contact number

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 circle)

• 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 Address

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

Please give further details below if necessary.

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

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