Breakfast Club Application Form

Information re Parent/s or Carer/s with full parental Responsibility

All boxes must be filled in. If not applicable please state N/A - Unless we have all the necessary information you will not be authorised to collect the child or receive notifications via Blossom
Parent or Carer 1

First NameLast Name
Do you have parental responsibility (parent or carer 1)
Address

Street Address

Street Address Line 2

CityCounty

Post Code
Relationship to child
Home Phone Number
Please enter a valid phone number.Format: (000)00000000.
Work Phone Number
Please enter a valid phone number.Format: (000) 00000000.
Mobile Phone Number
Please enter a valid phone number.Format: (000) 00000000.
Email
example@example.com
Parent or Carer 2

First NameLast Name
Do you have parental responsibility (parent or carer 2)
Address

Street Address

Street Address Line 2

CityCounty

Post Code
Relationship to child
Home Phone Number
Please enter a valid phone number.Format: (000)00000000.
Work Phone Number
Please enter a valid phone number.Format: (000) 00000000.
Mobile Phone Number
Please enter a valid phone number.Format: (000) 00000000.
Email
example@example.com
Starting Date Required

MonthDayYear
Date
Please state your ethnicity

Sessions required (subject to availability)
Please tell us your preferred days/times and we will endeavour to accommodate you
days/times
Is there any additional information we need to know about your child e.g. important likes, dislikes, cultural needs etc?
What other languages does your child speak at home?
Emergency contact with authority to pick up child

(in the event of the parent or carer being unavailable - 3 names are required)
Name of person 1

First NameLast Name
Relationship to Child
Contact Address 1

Street Address

Street Address Line 2

CityCounty

Post Code
Home Phone Number
Please enter a valid phone number.Format: (000) 00000000.
Work Phone Number
Please enter a valid phone number.Format: (000) 00000000.
Mobile Phone Number
Please enter a valid phone number.Format: (000) 00000000.
Email
example@example.com
Name of person 2

First NameLast Name
Relationship to Child
Contact Address 2

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number
Please enter a valid phone number.Format: (000) 00000000.
Work Phone Number
Please enter a valid phone number.Format: (000) 00000000.
Mobile Phone Number
Please enter a valid phone number.Format: (000) 00000000.
Email
example@example.com
Name of person 3

First NameLast Name
Relationship to Child
Contact Address 3

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number
Please enter a valid phone number.Format: (000) 00000000.
Work Phone Number
Please enter a valid phone number.Format: (000) 00000000.
Mobile Phone Number
Please enter a valid phone number.Format: (000) 00000000.
Email
example@example.com
Unique word for collection
Admission

We will only use your (including your child's name) personal information to provide a childcare service to you and we would like to keep sending you information so you can receive important updates about our nursery. We will keep your information secure and will never share it except if required to do so by law.
By ticking the yes box, you are consenting to us continuing to hold and processing your data and sending you information. You can of course unsubscribe / ask us not to contact you by email/phone etc at any time
I agree to the creation of Blossom online journals for my child to receive notifications for digital images and observations, invoices, newsletters and updates.
I have read and understood the information contained in the prospectus and the terms and conditions of Little Angels Day Nurseries and agreed to wholly abide by them.

I underdstand that this is a legally binding contract. This contract must be signed by all parties who have parental responsibilities for the child.
Name (parent / carer 1)

First NameLast Name
Relationship to Child
Relationship
Signature
Name (parent / carer 2)

First NameLast Name
Relationship to Child
Relationship
Signature
Please note: NO alterations can be made to this application form without the WRITTEN authorisation of the above signatories.

We do not have the right to withhold information from either parent without written evidence of legal intervention.
Should be Empty:

Little Angels Day Nursery & Pre School Breakfast & Afterschool Club Form East Tilbury Only

Allergies

Doctor

Dietary Requirements

Medication Details

Special Needs

Information re Parent/s or Carer/s with full parental Responsibility

Sessions required (subject to availability)

Emergency contact with authority to pick up child