CHILD INFORMATION RECORD

CHILD INFORMATION RECORD
Please complete the following. If you need to make any changes to the form throughout your child’s time at The Nursery, please ask for a new form.
Child's Name*

First NameLast Name
Date of Birth*

DayMonthYear
Date
Address*

Street Address

Street Address Line 2

CityPostcode

Postal / Zip Code
Name of Mother*

First NameLast Name
Email*
example@example.com
Telephone Number*
Name of Father*

First NameLast Name
Email*
example@example.com
Telephone Number*
Primary Language Spoken at Home*
Other Languages*
Emergency contact name*
Cannot be the same as Mother or Father
Emergency contact number*
Cannot be the same as Mother or Father
Relationship to child*
Cannot be the same as Mother or Father

Allergies*
Other information about your child (health concerns, special education needs or physical concerns, dietary requirements)

MEDICAL RECORD CARD
Name of G.P*
Telephone*
IMMUNISATION RECORD

DUE	IMMUNISATION
8 weeks old	DTaP/IPV/Hib/HepB
8 weeks old	MenB
8 weeks old	Rotavirus

Date*

DayMonthYear
Date

DUE	IMMUNISATION
12 weeks old	DTaP/IPV/Hib/HepB
12 weeks old	Pneumococcal conjugate vaccine (PCV)
12 weeks old	Rotavirus

Date*

DayMonthYear
Date

DUE	IMMUNISATION
16 weeks old	DTaP/IPV/Hib/HepB
16 weeks old	MenB

Date*

DayMonthYear
Date

DUE	IMMUNISATION
12 months old (on or after the child's first birthday)	Hib/MenC
12 months old (on or after the child's first birthday)	PCV booster
12 months old (on or after the child's first birthday)	MMR
12 months old (on or after the child's first birthday)	MenB booster

Date*

DayMonthYear
Date

DUE	IMMUNISATION
3yrs 4 months old (or soon after)	dTaP/IPV
3yrs 4 months old (or soon after)	MMR

Date

DayMonthYear
Date
If your child has not received any of the above vaccinations by the schedule above, you won't be able to submit the form so please contact the office.

Record of infections diseases

Whooping CoughMumpsScarlet FeverChicken PoxDiptheriaRubellaOther
Please specify other and add dates of your highlighted infections:
Record of illness, operations, accidents:
I give permission for staff at The Village Nursery to apply a dermatologically tested factor 50 sun cream to my child.
I warrant that to the best of my knowledge, the above is an accurate reflection of my child’s medical history.

CHILD COLLECTION FORM
I give permission for the following people to collect my child from The Barnes Village Nursery:
Name of person collecting*

First NameLast Name
Relationship to Child*
Contact Number*
I agree to inform my Group Leader if somebody other than myself will be collecting my child, even the above named persons, and I understand that if I fail to do so, my child will not be sent home until I can be reached and my consent received.

PHOTOGRAPHIC / VIDEOGRAPHIC CONSENT FORM
I agree not to publish any images I receive from The Barnes Village Nursery or through my child's Learning Journal as well as any taken at Nursery events on any social media or other website.
I agree to allow my child to be photographed by staff members on the premises of The Barnes Village Nursery / on outings organised by The Barnes Village Nursery throughout the school year for the purposes of records, evidence of activities and inspections. These photographs are only made available to staff and parents through our closed circuit online Learning Journals system and to OFSTED / Early Years professionals. I agree that should my child’s image inadvertently be in the background of an image taken of another child, The Barnes Village Nursery has permission to publish this image on this closed circuit site as part of the other Child’s Learning Journal.
I agree to allow my child to be photographed by The Barnes Village Nursery's professional photographer for the individual and group photographs, which are only made available to parents.I agree to allow other Parents / Interested Parties to Film or Photograph my Child as he or she participates in Nursery events such as The Christmas Concert, Summer Play, Sports Day, etc., to which parents are invited.I agree to allow my child to be photographed / video filmed for the purposes of promotional material of The Barnes Village Nursery, including, but not limited to, The Nursery’s Website and Promotional Literature.

OUTING CONSENT FORM
As we have a wonderful location here at The Barnes Village Nursery School, we have the unique opportunity to take the children for walks by the pond and in the surrounding area, as well as scheduling our Outside Learning Days.
I consent to Staff of The Barnes Village Nursery taking my child off nursery premises for outings during the school morning.

LEGAL ACCESS AND PARENTAL RESPONSIBILITY FORM
For the purpose of the Early Years Foundation Stage Statutory Framework, The Barnes Village Nursery must take necessary steps to safeguard and promote the welfare of children. It is a legal requirement that we have the following information:
Who has legal access to the child?
Name of Person 1*

First NameLast Name
Name of Person 2*

First NameLast Name
Who has parental responsibility for the child?
Name of Person 1*

First NameLast Name
Name of Person 2*

First NameLast Name

WORKING IN PARTNERSHIP FORM
To ensure your child gets the best quality and level of care, it helps to know if your child receives any additional education and care, in another setting, i.e. a registered childminder or any other registered nursery.

In order to comply with our statutory obligations with regards to 3 and 4-year-old funding, it is also necessary for parents to disclose if their child attends another setting/childminder.
My child does not receive education and care in another setting.
My child does receive education and care in another setting.
If so, please give details below:
Days of week child attends
Times
Type of registered care
Name of registered carer
I agree to allow The Barnes Village Nursery to share relevant information with the above mentioned provider in order to ensure a stable and caring environment and the best level of care for my child.
By signing below, I hereby confirm my acceptance of the indicated fields as well as that the information I have provided is correct to the best of my knowledge.
Signature*

Clear
Date*

DayMonthYear
Date
Email*
example@example.com
Should be Empty:

CHILD INFORMATION RECORD

MEDICAL RECORD CARD

IMMUNISATION RECORD

If your child has not received any of the above vaccinations by the schedule above, you won't be able to submit the form so please contact the office.

CHILD COLLECTION FORM

PHOTOGRAPHIC / VIDEOGRAPHIC CONSENT FORM

OUTING CONSENT FORM

LEGAL ACCESS AND PARENTAL RESPONSIBILITY FORM

WORKING IN PARTNERSHIP FORM