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
Date
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 ResposibilityPayment of FeesCollection of Child from Nursery
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*

Parent ResposibilityPayment of FeesCollection of Child from Nursery

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?*

YesNo
Does your child require long-term medication (e.g. Inhaler, Epi-pen)?*

YesNo
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?

Child Protection PlanChild in Need PlanSupport from Social WorkerSupport from Family Support WorkerOther
If yes, please provide information and contact details for any of the above services

	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.*

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	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