Nursery Consent Form
Please read and consent to the following nursery/baby room procedures
Child's name
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First Name
Last Name
Child's date of birth:
*
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Day
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Month
Year
Date
1. Emergency treatment declaration - In the event of an accident or emergency involving my child named above, I understand that every effort will be made to contact me immediately. Emergency services will be called as necessary, and I understand my child may be taken to hospital accompanied by the Head of Nursery (or authorised deputy) for emergency treatment and that health professionals are responsible for any decisions on medical treatment in my absence.
*
YES
2. Emergency administration of child-based paracetamol - In the event that my child named above develops a temperature in my absence, and it is recommended that child paracetamol is required, I give my permission for child-based paracetamol to be administered whereupon I (child’s parents or named emergency contacts) have been contacted prior to administration and on the understanding that I will be making arrangements for my child to be collected as soon as possible in accordance with the setting’s procedures on the administration of medicines.
*
YES
NO
Signature for paracetamol
3. Emergency administration of child-based antihistamine - In the event that my child named above presents with an allergic reaction in my absence, and it is recommended that antihistamine is required, I give my permission for a child-based antihistamine to be administered whereupon I(child’s parents or named emergency contacts) have been contacted prior to administration and on the understanding that I will be making arrangements for my child to be collected as soon as possible in accordance with the setting’s procedures on the administration of medicines.
*
YES
NO
Signature for antihistamine
4. Application of child-based teething gel or child-based teething granules - I give permission for teething gel or teething granules (supplied by me) to be applied to my child named above when necessary - in accordance with the manufacturer’s instructions. Staff will inform me by logging times of application on an administration of medication form and sharing this with me upon collection.
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YES
5. Application of nappy cream - I give permission for nappy cream (supplied by me) to be applied to my child named above when necessary - in accordance with the manufacturer’s instructions.
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YES
6. Application of sun cream - I give permission for sun cream (supplied by me) to be applied to my child named above when necessary. Please ensure you continue to apply the 8hr suncream as requested currently.
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YES
7. Application of face paint - We occasionally provide the opportunity for children to be face-painted. I give permission for face paint to be applied to my child named above when the activity arises.
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YES
NO
8. Animals - We may occasionally have supervised animal visits and ask for your permission so your child named above can be included in activities with any visiting animals. A risk assessment will be carried out for visiting animals, and parents informed. I give permission for my child to be included in activities with visiting animals and understand that appropriate hygienic and safety procedures will take place in accordance with risk assessments and policy. We will ensure that children with an aversion or those with allergies to animals will be included whilst being supported. I understand I will be informed, and my specific consent obtained.
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YES
NO
9. Outings - I give permission for my child named above to take part in short trips or general outings. I understand that individual risk assessments are carried out for each type of trip or outing taken and are available for me to see as required. For any planned outings, I understand I will be informed, and my specific consent obtained.
*
YES
NO
10. Sleeping (if applicable) - I understand that my child may fall asleep in another receptacle (buggy or bouncer) other than a Nursery sleep mat or bed and that attempts are made to transfer my child to a Nursery sleep mat or bed when the opportunity arises. I give permission for my child named above to fall asleep and sleep in a buggy or bouncer.
*
YES
NO
11. Vehicle Registration Number/s
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Please provide us with the Vehicle Registration numbers of anyone dropping off/collecting your child
Name of person completing this form
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First Name
Last Name
Relationship to child
*
Signature
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Date
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Day
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Month
Year
Date
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