Child's name
First name
Surname
Likes to be known (called)
Date of birth
/
Month
/
Day
Year
Date
School attending: BICKLEIGH DOWN C OF E PRIMARY SCHOOL
First language
School Year
Password (Compulsory - our staff will request this when collecting)
Start date
/
Month
/
Day
Year
Date
Parent/Guardian Details
Title
Name
First Name
Last Name
Home address
Does this child normally live at this address?
Yes
No
Work address
Email
example@example.com
Home number
Mobile number
Work number
Does this person have parental responsibility?
Yes
No
Title
Name
First Name
Last Name
Home Address (if didfferent from above)
Does this child normally live at this address?
Yes
No
Work address
Email address
example@example.com
Home number
Mobile number
Work number
Does this person have parental responsibility?
Yes
No
Does anyone else have parental responsibility for this child? (If yes, please detail)
i
Emergency Contact Details
Please provide details of two people we can contact if we can't get hold of you.
Name
Address
Telephone number
Mobile number
Relationship to child
Name
Address
Telephone number
Mobile number
Relationship to child
Child's Doctor
Name of Doctor
Address
Telephone Number
Authorised collection details for your child/ren
It is important that we are informed of anyone else apart from parents/carers, who are authorised to collect your child.
AUTHORISED COLLECTOR 1 Name
Home number
Relationship to child
Mobile number
Work number
AUTHORISED COLLECTOR 2 Name
Relationship to child
Home number
Mobile number
Work number
The collectors named above cannot be stopped from collecting your child unless a new form has been completed and signed.
I must inform you of any changes to the above list and I agree to my child being released into the care of those listed above.
Signature of Parent/Carer
Print Name
Date
/
Month
/
Day
Year
Date
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