Little Rosie's Nursery School Registration Form

Little Rosie's Nursery School

Registration Form
CHILD'S DETAILS
Child's Name

First NameLast Name
Date of Birth

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Gender
Nationality
Language(s) Spoken at Home
Religion
Address

Street Address

Street Address Line 2

CityCounty

Postcode
Family Collection Word
We operate a Family Collection Word system, in the instance of the usual person not being able to collect the child this word will be asked for. Parents/Carers must advise the nursery prior to the new person collecting the child. This word must remain confidential to the family/designated people responsible for collecting the child
PARENT/CARER 1 DETAILS
Parent Name

PrefixFirst NameLast Name
Gender
Address

Street Address

Street Address Line 2

CityCounty

Postcode
Mobile Telephone Number
Work Telephone Number
Email
example@example.com
Relationship to Child
Parent/Carer Responsibilities
PARENT/CARER 2 DETAILS
Parent Name

PrefixFirst NameLast Name
Gender
Address

Street Address

Street Address Line 2

CityCounty

Postcode
Mobile Telephone Number
Work Telephone Number
Email
example@example.com
Relationship to Child
Parent/Carer Responsibilities

COLLECTION FROM NURSERY

Please name who will be collecting your child from nursery
Name

First NameLast Name
Contact Number
Relationship to Child
Name

First NameLast Name
Contact Number
Relationship to Child
EMERGENCY CONTACTS

Please nominate 3 alternative emergency contacts, in case we are unable to contact you for any reason
Emergency Contact 1 Name

First NameLast Name
Contact Number
Relationship to Child
Emergency Contact 2 Name

First NameLast Name
Contact Number
Relationship to Child
Emergency Contact 3 Name

First NameLast Name
Contact Number
Relationship to Child

HEALTH INFORMATION
Does your child have any known allergies?
Does your child have any special dietary requirements?
Does your child have any medical conditions?
Does your child have any Special Needs or Disabilities?
Is your child up-to-date with their recommended immunisations?
Does your child require long-term medication (e.g. Inhaler, Epi-pen)?
If yes, please provide details
Name of GP Practice
GP Practice Address

Street Address

Street Address Line 2

CityCounty

Postcode
GP Contact Number
Health Visitor - If know, please provide details
Dentist - If registered, please provide details
Is your child under the care of any additional services?

Other
If yes, please provide information and contact details for any of the above services

Rows	If your child is attending for the funded hours, there is also a Parent Declaration Form to complete. Please complete the following:
Eligible Parent's Full Name
Parent's DOB
National Insurance Number
Funding Code
Date Code Received

Signature
By signing this form, you are confirming that: This application form has been correctly completed to the best of my knowledge. Completion of this form does not create any legally binding agreement with the nursery. Should any information change, I will inform and update the nursery as soon as possible.
Should be Empty:

Rows	Monday	Tuesday	Wednesday	Thursday	Friday
Breakfast Club (8:00am - 9:30am) £10 per day
Extended Day (12:30pm - 3:30pm £30 per day
AfterSchool Club (3:30pm - 5:30pm) £15 per day
Extra Morning Session (8:00am to 12:30pm)*
Extra Afternoon (1:00pm to 5:30pm)*

Little Rosie's Nursery School