New Customer Registration Form

Section 4

Medical information/contacts-Please provide details of any medical conditions of which the nursery team should be aware (eg. Asthma, allergies, eyesight, hearing problems, speech therapy, epilepsy)
Does the child have any medical conditions,disability,additional support needs or receive regular medication*

YesNo
Doctors Surgery*
Doctors surgery phone number
Please enter a valid phone number.
Doctors surgery address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Health Visitor*
Health Visitor phone number
Please enter a valid phone number.
Health Visitor email
Are there any other professionals currently involved with the child? (eg. Social Worker, Educational Psychologist, Speech & Language Therapist etc)*

YesNo
If Yes to any of the above please provide further details
How did you hear about us?*
Please Specify*

Section 5
Do you give permission for staff to apply sun block/midge repellent to your child if deemed necessary?

YesNo
Do you require to provide information relating to religion eg.observance of religious festivals, prohibited foods?

YesNo
Does your child have any non medical dietary requirements eg. vegan, vegetarian , no e numbers?

YesNo
If yes please provide further details
Section 6

Ethnic Background- You are not required to complete these questions however the information is extremely valuable as it is used to check that equal opportunities are offered to all children
Childs first language
Other languages spoken
Childs ethnic origin
Section 7
Any other relevant information
The information on this form is covered by the DATA PROTECTION ACT and will be entered into a computer system for the purpose of Early Years administration

Little Bugs LTD can not be held responsible for the consequences of non disclosure of information

Section 1 Child details