Wild Bugs
Abercorn, Hopetoun Estate
Section 1 - Child's Details
Have you been to visit Little Bugs?
My child currently attends nursery at Little Bugs Abercorn or Fordell Firs
Yes
No
Child's Full Name
First Name
Last Name
Known as
Child's Date of Birth
-
Day
-
Month
Year
Date
Gender
Male
Female
Child's Home Address
Street Address
Street Address Line 2
Town/City
County
Post Code
Desired Start Date
-
Day
-
Month
Year
Date
Section 2 - Emergency Contact Details
Name
First Name
Last Name
Contact Number
-
Area Code
Phone Number
Email
example@example.com
Relationship to Child
Lives at the same address as child
Can collect child
Occupation (optional - to support home-link learning)
Name
First Name
Last Name
Contact Number
-
Area Code
Phone Number
Email
example@example.com
Relationship to Child
Lives at the same address as child
Can collect child
Occupation (optional - to support home-link learning)
Section 3 - Sessions Requested
Rows
9am - 3pm (term time only)
Monday
Tuesday
Wednesday
Thursday
Friday
Which primary school does/will your child attend, if any?
Section 4 - Medical/Health Information
Please provide details of any medical conditions of which the flexi-school team should be aware (e.g. asthma, allergies, eyesight/hearing problems, speech therapy. epilepsy etc.)
Does your child have any medical conditions, disabilities, allergies, additional support needs or receive regular medication?
Yes
No
If yes, please provide details (if no, please write 'not applicable'):
*
Doctors Surgery
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
Town/City
County
Post Code
Name of Health Visitor
First Name
Last Name
Health Visitor Contact Number
-
Area Code
Phone Number
Are there any other professionals currently involved with the child (e.g. Social Worker, Educational Psychologist, Speech and Language therapist)?
Yes
No
If yes, please provide details and contact information (if no, please write 'not applicable'):
*
Do you give permission for staff to apply sun block/midge repellent to your child if deemed necessary?
Yes
No
Do you need to provide information relating to religion e.g. observance of religious festivals or prohibited foods?
Yes
No
Does your child have any non medical dietary requirements e.g. vegan, vegetarian, no e numbers?
Yes
No
If yes, please provide further details:
Section 5 - Ethnic Background
You are not required to complete these questions, however the information is extremely valuable as it is used to ensure equal opportunities are offered to all children.
Child's First Language
Child's Ethnic Origin
Section 6 - Any Other Relevant Information
Please provide details here:
Section 7 - Permissions
I declare my child medically fit to participate in Little Bugs outdoor activities both on and off site. I undertake to notify Little Bugs Nursery in the event of any change to my child's health. I understand that there is an element of risk involved in taking part in outdoor activities and I accept the risk. In the case of an incident, I give Little Bugs Nursery personnel the authority to administer any first aid treatment considered necessary to preserve my child's life. I agree to emergency medical, surgical and dental treatment being administered to my child, as considered necessary by professional medical authorities.
I consent
I do not consent
I accept that personal belongings are not covered by Little Bugs insurance and that Little Bugs will not be held liable for damage to or loss of these items.
I consent
I do not consent
Photographs and videos are taken during Little Bugs sessions. These will be used in our assessment, evaluation and monitoring processes.
I consent
I do not consent
At times these photographs and videos may be used in Little Bugs publicity, publications and on our website, including social media. At times the press may ask to take photographs of the children involved in nursery activities.
I consent
I do not consent
I consent to my personal email being added to the Little Bugs Parent mailing list. This list will be used to provide information/updates regarding the nursery, provide induction materials and marketing of upcoming nursery events. At no time will your email given, sold or passed on to a third party without consent.
I consent
I do not consent
I understand that I have to give 4 weeks notice to change or terminate my child's space at Little Bugs. I agree I will be liable to pay 4 weeks worth of fees should I choose to withdraw my child from the service.
I consent
I do not consent
I have read and accept the Terms and Conditions outlined by Little Bugs Nursery.
Yes
No
Signature of Parent/Guardian
Name
First Name
Last Name
Date
-
Day
-
Month
Year
Date
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