Tots and Juniors Registration Form

10.4 Registration Contract - Pre School

Tots & Juniors's 10B Wentworth Rd Rushden Northants
Name

Child's first name(s) Surname
Birth certificate seen and copy made

Yes No
Name known as
Child's full address
Gender
Date of birth

Month Day Year
Date
Family details
Contact details 1 (including emergency information):
Parent/carer full name
Relationship to child
Daytime/work telephone
Mobile
Home telephone
Email
example@example.com
Home address (if different from childs)
Does this parent have parental responsibility for the child?

Yes No
Work address
Contact details 2 (including emergency information):
Parent/carer full name
Relationship to child
Daytime/work telephone
Mobile
Home telephone
Email
example@example.com
Home address (if different from childs)
Does this parent have parental responsibility for the child?

Yes No
Work address
Other person(s) with legal contact To be completed where those persons with parental responsibility are separated and a court order is in place.
Name
Address
Contact telephone numbers
Relationship to child
What are the contact arrangements that Tots & Juniors need to be aware of?
Emergency contact details if parents are not available Emergency contacts must be local.
Contact 1 Name
Relationship to child
Address
Daytime/work telephone
Home telephone
Mobile
Contact 2 Name
Relationship to child
Address
Daytime/work telephone
Home telephone
Mobile
Persons other than parent(s) authorised to collect the child Must be over 16 years of age. Please note that if the authorised person is not the person indicated on the daily signing in/out sheet, staff will check before releasing the child.
Person 1 Name
Relationship to child
Address
Daytime/work telephone
Home telephone
Mobile
Person 2 Name
Relationship to child
Address
Daytime/work telephone
Home telephone
Mobile
Person 3 Name
Relationship to child
Address
Daytime/work telephone
Home telephone
Mobile
Password for the collection of child by authorised persons
Health and development Has your child received the following immunisations? Please confirm and provide date of immunisations given.
5-in-1 (DTaP/IPV/Hib) vaccine - diphtheria, tetanus,

Yes No
Date

Month Day Year
Date
pertussis (whooping cough), polio and Haemophilus influenzae type b (Hib
Pneumococcal (PCV) vaccine.

Yes No
Date

Month Day Year
Date
Rotavirus vaccine.

Yes No
Date

Month Day Year
Date
Three months old 5-in-1 (DTaP/IPV/Hib) vaccine, second dose. diphtheria, tetanus, pertussis (whooping cough), polio and Haemophilus influenzae type b (Hi

Yes No
Date

Month Day Year
Date
Meningitis C vaccine.

Yes No
Date

Month Day Year
Date
Rotavirus, second dose.

Yes No No
Date

Month Day Year
Date
4 month old 5-in-1 (DTaP/IPV/Hib) vaccine, third dose - diphtheria, tetanus, pertussis (whooping cough), polio and Haemophilus influenzae type (Hib)

Yes No
Date

Month Day Year
Date
Pneumococcal (PCV) vaccine, second dose.

Yes No
Date

Month Day Year
Date
Between 12 & 13 months old. Hib/Men C booster - Haemophilus influenza type b (Hib), forth dose and meningitis C, second dose.

Yes No
Date

Month Day Year
Date
MMR vaccine - mumps, measles and rubella.

Yes No
Date

Month Day Year
Date
Pneumococcal (PCV) vaccine, third dose.
Yes No
Date

Month Day Year
Date
Two to Three years. Flu Vaccine

Yes No
Date

Month Day Year
Date
Three years & four months or soon after. MMR vaccine, second dose - mumps, measles and rubella

Yes No
Date

Month Day Year
Date
4-in-1 (DTaP/IPV) pre-school booster - diphtheria, tetanus, pertussis (whooping cough) and polio.

Yes No
Date

Month Day Year
Date
For internal use: Has the child's health record book been seen to confirm immunisation dates?

Yes No
Does your child have any on going medical conditions? If so, please specify
If yes, please specify which external agencies are involved e.g. Paediatrician, Consultant, Dietician, Speech and Language Therapist, etc
Does your child require a health care plan?

Yes No
Is your child known to have any allergies or food intolerances? If so, please specify
A risk assessment will be completed and kept on the child's file for any known allergies or food intolerance as mentioned above.
What are your child's dietary requirements? Please specify
It is Tots & Juniors usual practice to provide both a meat and vegetarian option. If this is not in-keeping with your child's dietary requirements, please discuss this with our setting manager to ensure that we are working in partnership to meet your child's needs. Please refer to our Food and Drink Policy.

If your child is aged three years or over, does he or she have difficulty with any of the following:
Speaking and communicating

Yes No
Listening and attending

Yes No
Understanding simple instructions

Yes No
Eating and drinking

Yes No
Sitting and sharing a book

Yes No
Rolling a ball

Yes No
Walking and climbing

Yes No
Holding a crayon

Yes No
Socialising with adults and other children

Yes No
Using the toilet

Yes No
Putting on their shoes and socks

No Yes
Any other concerns
Does your child have any special needs or disabilities? If so, please specify
Are any of the following in place for the child?

SEN action plan Education, Health and Care Plan
What special support will he/she require in our setting?
Two year old progress check - children aged 24 - 36 months

If your child is aged between 24-36 months, has a two year old progress check already been completed for
Yes
No
Setting completing check
Date completed

Month Day Year
Date
As per the requirements of the Early Years Foundation Stage we will complete a progress check on your child between the ages of 24-36 months. We will ask you to be involved in completing the check and will discuss it with you.
What is the main religion in your family (if applicable)?
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 at Tots & Juniors?
What language(s) is/are spoken at home?
If English is not the main language spoken at home, will this be your

child's first experience of being in an English-speaking environment?
Does your child need a bilingual support plan?
No No
If so, discuss and agree with the key person how we can work together to support your child when settling in
Details of professionals involved with your child
GP Name
Telephone
Address
Health Visitor (if applicable)
Name
Telephone
Address
Social Care Worker (if applicable)
Name
Telephone
Address
What is the reason for the involvement of the social care department with your family? NB If the child has a child protection plan, make a note here, but do not include details. Tots & Juniors will ensure these details are obtained from the social care worker named above and keep these securely in the child's file.
Any other professional who has regular contact with the child Name 1
Role
Agency
Telephone
Address
Name 2
Role
Agency
Telephone
Address
Key persons - Information for parents Each child joining the setting who is age 5 or under, will have a key person appointed to them. It will be the key person's responsibility to ensure that your child receives the best possible attention whilst in Tots& Juniors care and to ensure that their records are kept up-to date. Your child's key person may change as your child progresses through the setting. You will be notified of these changes. Your child's key person is your first point of contact for anything you wish to discuss about your child.
Your child's key person will be
Date starting at Tots & Juniors

Month Day Year
Date
Days and times of attendanceMon -
Mon
Tue
Wed
Thu
Fri
Are any fees payable? If so, note here
Has the settling-in period been agreed?

Has the settling-in period been agreed? Yes No
If so, please specify
Policies and procedures I have been provided with details of Tots & Juniors prospectus for parents, and its policies and procedures. The policies and procedures have been explained to me, including the Information Sharing Policy, and I understand that there may be circumstances where information is shared with other professionals or agencies without my consent in line with Tots & Juniors Privacy Notice 2018. I understand and agree to follow all
Signed

Clear
Date

Month Day Year
Date
Printed name
Please sign below to indicate that the information given on this registration contract is accurate and correct, and that you will notify us of any changes as they arise. If at any point I wish to cancel or reduce my child's

contracted sessions, I will provide four weeks notice in writing.
Parent name
Signed

Clear
Date

Month Day Year
Date
Name of manager
Signed

Clear
Date

Month Day Year
Date
Ethnicity - Gathered for monitoring purposes only. Parents are not obliged to complete this data.

White British White Irish White other Black British Black African Black Caribbean Black other White and Black Caribbean White and Black African White and Black Asian Bangladeshi× Pakistani Chinese Chinese other Asian other
Other please state
, A child’s learning difficulties and disabilities status should be recorded according to the following categories: (Providers should refer to the SEND Code of Practice for the Early Years, for an explanation of the terms below)

No special educational need SEN action plan Education, Health & Care Plan
Childs Name:
Parent Name:
Sign

Clear
Date

Month Day Year
Date
Should be Empty: