Consent Form

Consent Form

This form is only the consent form. The information we are gaining consent to share can be found on your child's Famly account under NOTES or Documents
Child's Name

First NameLast Name
Child's Date of Birth

DayMonthYear
Date
Parent's Name

First NameLast Name
Peekaboo Childcare require your consent for the following - please select the reasons from the list below. You can select more than one if necessary

Speech and Language therapyPortageChildren ServicesHealth visitorEducational PsychologistPrimary School or new setting/nurseryALFEY PanelApprenticeship agency (for training)Health Care PlanEarly Help referralMASH referralOther
By signing this form I am agreeing that I have completed the following things:

- read the information being shared

- rasied any concerns I have with the staff at Peekaboo

- had the information changed if I felt is was incorrect

I am giving my consent for this information to be shared with the agencies that have been selected.
Parent/care giver Signature

Clear
Date signed

DayMonthYear
Date
Should be Empty: