South Cerney Pre-School Playgroup Registration Form

 

To be completed by childs parent/guardian

FULL NAME OF CHILD ________________________Date of birth___________________

Address _________________________________________________________________

________________________________________________________________________

_________________________________________________Post code________________

Name of Parents/Guardians ___________________________________________________

Address if different ________________________________________________________

Home Telephone Number_____________________________________________________

Work Telephone Number _____________________________________________________

Other children in Family_____________________________

E.G Only child/eldest_______________________________

Ethnic Origin ____________________________________ Religion___________________

Home Language(s)__________________________________________________________

It may be helpful to know which languages are spoken and written in the home and if translation would help communication with parents.

Does your child drink milk? Yes/No

Does your child have any health problems or dietary requirements? Yes/No

If yes please give details _________________________________________

____________________________________________________________

Does your child need any medication? Yes/No

If yes please give details _________________________________________

____________________________________________________________

Immunisations Diptheria, Tetanus, Whooping Cough/Polio ____________

(please give details) Measles, Mumps, Rubella ____________

HIB ____________

Names of people authorised to collect your child________________________

____________________________________________________________

Is permission given for walks and visits outside Playgroup Yes/No

Name of Doctor ___________________ Telephone Number _________________________

Address _________________________________________________________________

Other professionals involved with the family, e.g Health Visitor, Social Worker.

Name, job title and telephone number.

	Emergency Contact 1	Emergency Contact 2
Name
Address
Contact Number

Please give details for emergency medical procedures which are forbidden by family religions/Beliefs ___________________________________________________________

Is permission given for emergency medical procedures others than listed above Yes/No

________________________________________________________________________

Is permission given in the case of a serious accident for a member of staff to take/accompany your child to hospital in an ambulance Yes/No

If in doubt when your child seems unwell it is better for them to stay at home

I am available to do my ROTA duty on: Mon Tues Weds Thurs Fri Please circle

I agree to pay a fee of £10.00 if I cannot do my ROTA duty or find cover.

Signed ___________________________________ Date ___________________

Parent/Guardian

Please use the space below for any other information about your child which you think would be useful to us and which would help your child be happy at Playgroup.