Form
CHILD'S DETAILS
Name
First Name
Last Name
Middle Name
Gender M/F
D.O.B
Age of child
Home Telephone Number
Mobile Telephone
Email (for correspondence)
Medical Conditions/ Dietary Needs
Is any regular medication required?
Ethnicity?
Nationality?
First Language?
Second Language?
What Nursery or School does your child attend?
GP/Doctor
Tele.
Surgery Address
Please give detail of all persons with parental responsibility and anyone else you wish to be contacted in an emergency. Please place them in the. order that you wish for them to be contacted in an emergency.
PARENT/ GUARDIAN DETAILS 1
Forename
surname
Title
Work Tel.
Mobile Tel.
Email
Company/ Employer and Address Contact No.
Home Address
PARENT/ GUARDIAN DETAILS 2
Forename
Surname
Title
Work Tel.
Mobile Tel.
Company/Employer Address and Contact No.
Home Address
EMERGENCY CONTACT DETAILS 3
Forename
Surname
Title
Work Tel.
Mobile No.
Email.
Address
Relationship to child
PHOTOGRAPHS
Social Media and marketing Preferences
Do you give permission for images of your child to be used for marketing purposes. Such as in third-party publications, posters, flyers and advertisements for Shoresh. Images will be carefully, and sensitively chosen and will not be used out of context. Children will not be named. Please note, that should you withdraw consent, it may not be possible to change printed publications, such as the prospectus, or third- party publications. However, we will remove the images from future prints
I give permission
I don't give permission
Do you give permission for your child to photographed on social media sites, such as Instagram and Linked In. Images will be carefully selected, and sensitively chosen and will not be used out of context. Children will not be named.
I give permission
I don't give permission
ADMINISTRATION OF MEDICATION
If whilst your child is at Shoresh and they suddenly come down with a high temperature we need the following consent signed in order for us to administer Calpol, or similar. We also need to have a supply of your own Calpol on site as we are no longer permitted to supply this. We will happily hold two sachets of Calpol for your child but this needs to be clearly named and provided.
I give consent for Shoresh to administrate Calpol to my child and I will provide two sachets of Calpol for my child that is clearly labeled and named.
I do not give consent for Shoresh to administrate Calpol to my child.
I understand that in the event of child becoming ill or them having a temperature, I will be contacted and will come and collect my child.
Agree
Terms and Conditions
Please tick
I understand that only the parent/guardian that drops the child to the session is authorised to collect the child.
Agree
I understand that unless negligent or guilty of some other wrong doing causing injury, loss or damage, the Nursery does not accept responsibility for accidental injury or other loss caused to the child or the parents or for loss or damage to property.
Agree
I agree to the Nursery making suitable medical decisions and seeking medical help if we cannot be contacted.
Agree
I agree that the late collection of my child will result in a late collection fee, payable on the day, charged at the rate of £5 per 15 mins or part thereof.
Agree
I understand that there is a £5 registration fee payable with this form. This will enable you to continue booking future holiday club sessions and ad hoc 'Gym & Play' Sessions in the future.
Agree
I confirm that I will read a copy of Shoresh's Safeguarding Policy.
Agree
In order to comply with government GDPR 2018 legislation we hold information both digitally & in paper form during your child’s attendance at Shoresh & for a required legislative period of time. This is information provided by you when registering or that you have provided upon our request and is used so we can contact you effectively. You are able to access any held information at any time following a written request and we agree to provide this information to you within one month. In line with our privacy and safeguarding policies and procedures if deemed necessary we are required by law to share any relevant information with relevant external agencies.
Agree
I CONFIRM THAT THE ABOVE IS CORRECT AND THAT I WILL INFORM SHORESH OF ANY CHANGES IMMEDIATELY
I Confirm
Print Name
Signature
Date
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