Clone of A-Level Minds Application Form

Application Form

Full Name of Child

First NameLast Name

Name Usually Known By

Date of Birth

MonthDayYear

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Gender

MaleFemale

Mother's Details

Name

First NameLast Name

Occupation

Employer

Address (If different from child's)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Number

Cell Number

Please enter a valid phone number.

Work Number

Please enter a valid phone number.

E-mail Address

example@example.com

Father's Details

Name

First NameLast Name

Occupation

Employer

Address (If different from child's)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Number

Cell Number

Please enter a valid phone number.

Work Number

Please enter a valid phone number.

E-mail Address

example@example.com

Who has parental responsibility?

Name

First NameLast Name

Name

First NameLast Name

Are there any contact restrictions? (If yes, please provide details below).

YesNo

Restrictions (if any):

Emergency Information

Emergency Contact's Name

First NameLast Name

Relationship to Child

Phone Number

Alt. Phone Number

Other Emergency Contact's Name

First NameLast Name

Relationship to Child

Phone Number

Alt. Phone Number

Please indicate the days and times you want your child to attend:

	Morning	Afternoon	Full Day
Monday
Tuesday
Wednesday
Thursday
Friday

Medical Details

Does your child have any medical problems that we should be made aware of? Please give details below.

Does your child have any allergies that we should be made aware of? Please give details below.

Is your child on any long-term medication that we should be made aware of? Please give details below.

Does your child have any special dietary requirements? (e.g., vegetarian). Please give details below.

Permissions

	Yes	No
Do you give the daycare permission to take photographs of your child for development files?
Do you give the daycare permission to take photographs of your child for promotional purposes?
Do you give the daycare permission to use sunscreen (factor 15+)?
Do you give the daycare permission to use baby wipes/teething gel/sudocream?
Do you give the daycare permission to administer first aid?
Do you give the daycare permission to take your child on outings to local shops, etc?
Do you give the daycare permission to administer paracetamol suspension, if needed?

Collection Arrangements

Who is authorized to collect your child from daycare other than parents? Your child will only be allowed to leave the daycare with the people listed here. Any changes to this information should be made in writing to the Daycare Manager.

Name

First NameLast Name

Relationship to Child

Name

First NameLast Name

Relationship to Child

As an extra precaution, you may use a password. Anyone collecting your child should be made aware.

Password

I understand and acknowledge that the fee due to A-Level Minds is to be paid per calendar month and is paid one month in advance, directly into the bank and non-refundable in case of absence. I further agree to give one month's notice or payment in lieu of notice if I wish to withdraw my child from daycare. I understand that failure to pay said fees may result in loss of childcare provision.

Confirmation BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Signature

Date