Child's Enrolment Form

Child's Enrolment Form
Little Harvard Location
Please choose from the list below*

Blanchardstown BallycoolinBray Upper DargleDonabateKinsealy MuileannLeixlip Barnhall MeadowsLeixlip Captains HillLeixlip WestfieldLeixlip Beech ParkMaynooth Carton WoodRathnew MerrymeetingRathnew Kirvin HillRathfarnham Taylors HillRathfarnham Barton DriveRathfarnham ScholarstownSwords HolywellSantry NorthwoodSantry BlackwoodKilcock Ledwill ParkGreystones, WicklowNewbridge Belin WoodBroomhall, RathnewGreenlane, Leixlip
Required Start Date*

DayMonthYear
Date
Type of Placement*

Full Time ChildcareAfterschoolECCE
School your child attends
Average Weekly Term Hours*
Average Weekly Holiday Hours*
Please note that these hours will be used to apply for your funding and should be as accurate as possible, any change in hours should be communicated to your accounts executive as soon as possible. Overclaimed hours can result in funding being clawed back.*

Agree
Term Time
Drop off at Little Harvard Time*

Hour Minutes

AM/PM Option
Collect from Little Harvard Time*

Hour Minutes

AM/PM Option
School Start Time*

Hour Minutes

AM/PM Option
School End Time*

Hour Minutes

AM/PM Option
Non-Term Time
Drop off at Little Harvard Time*

Hour Minutes

AM/PM Option
Collect from Little Harvard Time*

Hour Minutes

AM/PM Option
Days Needed for Crèche Care*

MondayTuesdayWednesdayThursdayFriday
Days Needed for After School

MondayTuesdayWednesdayThursdayFriday
ECCE Sessional Only

MondayTuesdayWednesdayThursdayFriday
Notes
Child's Details
Child's Name (as it appears on birth certificate)*
Known as (if different from above)
Name
Date of Birth*

DayMonthYear
Date
Sex: Male/Female*

MaleFemale
Address*

Street Address

Street Address Line 2

CityCounty

Eircode
Child's First Language*
Parents/Guardian Details
Parent 1 - Name*
Mobile*
Please enter a valid phone number.
Landline

Area CodePhone Number
Parent 1 Email*
example@example.com
Parent 1 Address - Same as above?

YesNo
Parent 1 Address

Street Address

Street Address Line 2

CityState / Province

Eircode
Parent 2 - Name
Mobile
Please enter a valid phone number.
Landline

Area CodePhone Number
Parent 2 Email
example@example.com
Address - Same as above?

YesNo
Parent 2 Address

Street Address

Street Address Line 2

CityState

Eircode
Do you wish to add another Guardian’s details?

YesNo
Other Guardian
Please state relationship to child
Guardian Email
example@example.com
Mobile
Please enter a valid phone number.
Landline

Area CodePhone Number
Guardian Eircode

Street Address

Street Address Line 2

CityState / Province

Eircode
Additional Text
Primary Contact*

Parent 1 - details as aboveParent 2 - details as aboveGuardianOther
Contact Name
Other Email
example@example.com
Mobile
Please enter a valid phone number.
Alternative Emergency Contact
Emergency Contact Name
Mobile*
Please enter a valid phone number.
Landline Number

Area CodePhone Number
Email*
example@example.com
Alternative contact Address*

Street Address

Street Address Line 2

CityState / Province

Eircode
Authorisation
Are other people authorised to collect my child?*

YesNo
Authorised Person's Name
Authorised Person's Relationship to Child
Authorised Phone Number

Area CodePhone Number
Doctors Details
Doctors Name*
Doctors Landline*

Area CodePhone Number
Doctors Mobile
Please enter a valid phone number.
Doctors Email*
example@example.com
Doctors Address*

Street Address

Street Address Line 2

CityState / Province

Eircode
Immunisation Record
(2 Months) 6 in 1 + MenB* + PCV +Rotavirus

YesNo
Please enter date of 6 in 1 + MenB* + PCV +Rotavirus

DayMonthYear
Date
(4 Months) 6 in 1 + MenB* + Rotavirus

YesNo
Please enter date of 6 in 1 + MenB* + Rotavirus

DayMonthYear
Date
(6 Months) 6 in 1 + PCV + MenC

YesNo
Please enter date of 6 in 1 + PCV + MenC

DayMonthYear
Date
(6 Months) 6 in 1+ Men C+ PCV Vaccination

YesNo
Please enter date of 6 in 1 + PCV + MenC*

DayMonthYear
Date
(12 Months) MMR + MenB

YesNo
Please enter date of MMR + PCV Vaccination

DayMonthYear
Date
(13 Months) Hib/MenC + PCV

YesNo
Please enter date of Hib/MenC + PCV

DayMonthYear
Date
Special / Additional Needs
In order to allow us to meet/support your child can you please inform us if your child has any of the following:
Medical Condition(s)*

YesNo
As you answered 'Yes', we require additional information.
Medical Condition(s)
Additional needs e.g. physical, intellectual*

YesNo
As you answered 'Yes', we require additional information.
Additional needs e.g. physical, intellectual
Hearing or speech difficulties*

YesNo
As you answered 'Yes', we require additional information.
Hearing or speech difficulties
Allergies e.g. food, medicine, other pollutants*

YesNo
As you answered 'Yes', we require additional information.
Allergies e.g. food, medicine, other pollutants
Specific cultural/dietary requirements*

YesNo
As you answered 'Yes', we require additional information.
Specific cultural/dietary requirements
Parental Consent Form
Emergency Medical/Treatment Care

I give my permission for my child to be given appropriate emergency medical treatment in the case of an emergency. I understand that every effort will be made to contact the named guardian or next of kin in the event of an emergency, requiring medical attention. However, if none of these can be contacted I hereby authorise the Little Harvard service to transport my child to the doctor's surgery or to the appropriate hospital A/E department by ambulance or as is necessary and to secure the necessary medical treatment for my child.
Emergency Medical/Treatment Care*

Clear
I give my permission for my child to be given appropriate emergency medical treatment in the case of an emergency.
First Aid*

Clear
I authorise that staff trained in First Aid may administer First Aid to my child as appropriate.
Parental Consent Form Signature. Please sign below to give consent to Emergency Medical/Treatment Care
Additional Medical Requirements*

YesNo
As you answered 'Yes', we require additional information.
Additional Medical Requirements
Change Of Clothes*

Clear
I hereby give permission for my Childs clothes to be changed should the need arise.
Child Observation Permission*

Clear
Child observations will be used in the creche setting to ensure that all the individual needs of children are met through the creche curriculum and programme. I give permission for child observations to be conducted in the creche setting, as outlined in the policy and procedures of the creche setting.
Infectious Diseases*

Clear
Parent/Nursery Childcare Declaration*

Clear
Parental Consent Form Signature. Please sign below to give consent to these actions as stated above. Emergency Medical/Treatment Care | First Aid | Antifebrile | Allergies | Change Of Clothes | Child Observation Permission | Infectious Diseases | Parent/Nursery Childcare Declaration
Photo and Video Permission*

Clear
We look to sometimes employ pictures and videos of your child for our website and for our social media, with your permission. We take photographs and capture footage of your children’s activities to display in our premises, to put up on our website and to create content on our social media platforms. This content is captured to assist in the child’s education; and to inform parents and staff of the activities that are undertaken by the children on a daily basis. This consent can be withdrawn at any time by emailing the manager of your respective crèche. Put ‘consent’ as the subject and state the name of your child/children. We will then ensure their photographs won’t be used. A list of these emails can be found on our website, under the ‘Contact’ tab.
Date of Signature*

DayMonthYear
Date
Type Your Name to confirm your signature*
Permissions
Trip/Outing/Walk Permission*

YesNo
Photo and Video Permission*

Yes, I consentNo, I do not consent
Printed Photograph Usage*

YesNo
Access to Animals/Insects*

YesNo
Sun Cream Permission*

YesNo
Data privacy
Consent for Collection and Usage of your personal data

Please ensure that all parents or guardians whose information has been supplied in this form read and complete the following. I have read the Service’s Privacy Notice, and I understand the reasons for requesting the personal information sought about myself and my child in this Registration form. I consent to the collection and processing of the data given, for these purposes, by Little Harvard. I understand that I can request a copy of this information, and revise or withdraw my consent by contacting the service at any time.
Terms & Conditions*
Parent or Guardian’s signature (1)*

Clear
Parent or Guardian’s signature (2)

Clear
Signature - Confirming you have read and agree to our terms*

Clear
Date of Signature*

DayMonthYear
Date
Type Your Name to confirm your signature*

First NameLast Name
The form will be emailed to the primary contact.
Should be Empty:

Child's Enrolment Form

Little Harvard Location

Child's Details

Parents/Guardian Details

Alternative Emergency Contact

Authorisation

Doctors Details

Immunisation Record

Special / Additional Needs

Parental Consent Form

Parental Consent Form Signature. Please sign below to give consent to Emergency Medical/Treatment Care

Permissions

Data privacy

The form will be emailed to the primary contact.