Child's Enrolment Form

Child's Enrolment Form
Little Harvard Location
Please choose from the list below
Required Start Date

DayMonthYear
Date
Type of Placement
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.
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
Days Needed for After School
ECCE Sessional Only
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
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.Format: 000-000-0000.
Landline

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

Street Address

Street Address Line 2

CityState / Province

Eircode
Parent 2 - Name
Mobile
Please enter a valid phone number.Format: 000-000-0000.
Landline

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

Street Address

Street Address Line 2

CityState

Eircode
Do you wish to add another Guardian’s details?
Other Guardian
Please state relationship to child
Guardian Email
example@example.com
Mobile
Please enter a valid phone number.Format: 000-000-0000.
Landline

Area CodePhone Number
Guardian Eircode

Street Address

Street Address Line 2

CityState / Province

Eircode
Additional Text
Primary Contact
Contact Name
Other Email
example@example.com
Mobile
Please enter a valid phone number.Format: 000-000-0000.
Alternative Emergency Contact
Emergency Contact Name
Mobile
Please enter a valid phone number.Format: 000-000-0000.
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?
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.Format: 000-000-0000.
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
Please enter date of 6 in 1 + MenB* + PCV +Rotavirus

DayMonthYear
Date
(4 Months) 6 in 1 + MenB* + Rotavirus
Please enter date of 6 in 1 + MenB* + Rotavirus

DayMonthYear
Date
(6 Months) 6 in 1 + PCV + MenC
Please enter date of 6 in 1 + PCV + MenC

DayMonthYear
Date
(6 Months) 6 in 1+ Men C+ PCV Vaccination
Please enter date of 6 in 1 + PCV + MenC

DayMonthYear
Date
(12 Months) MMR + MenB
Please enter date of MMR + PCV Vaccination

DayMonthYear
Date
(13 Months) Hib/MenC + PCV
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)
As you answered 'Yes', we require additional information.
Medical Condition(s)
Additional needs e.g. physical, intellectual
As you answered 'Yes', we require additional information.
Additional needs e.g. physical, intellectual
Hearing or speech difficulties
As you answered 'Yes', we require additional information.
Hearing or speech difficulties
Allergies e.g. food, medicine, other pollutants
As you answered 'Yes', we require additional information.
Allergies e.g. food, medicine, other pollutants
Specific cultural/dietary requirements
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

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

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

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

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

Infectious Diseases* To help protect the health and wellbeing of all children and staff, parents/guardians are required to inform the crèche if their child has been diagnosed with, or is suspected of having, an infectious illness. Children who display symptoms of an infectious disease may be required to remain at home for the recommended exclusion period, in line with HSE and public health guidelines. Parents/guardians agree to cooperate with the crèche in managing infectious illnesses and to keep their child at home when unwell. I understand that, where necessary, the crèche may share relevant information with parents and/or public health authorities in accordance with data protection requirements, while maintaining confidentiality at all times. I acknowledge and accept the crèche’s Infectious Diseases policy and procedures.
Parent/Nursery Childcare Declaration

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

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
Photo and Video Permission
Printed Photograph Usage
Access to Animals/Insects
Sun Cream Permission
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)
Parent or Guardian’s signature (2)
Signature - Confirming you have read and agree to our terms
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.