Be. Independent Day Nurseries

Registration Form

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Child’s Details:

Child’s Full Name

Date of Birth

Gender

Same gender assigned at birth?

Yes

Position in Family

Start Date

Nationality

Ethnicity

Languages spoken at home

If English is not the main language spoken at home, will this be your child’s first experience of being in an English speaking environment?If English is not the main language spoken at home, will this be your child’s first experience of being in an English speaking environment?

Parent / Guardian’s Full Name and Address:

Telephone Numbers

Mobile Number

Work Email 1

Work Email 2

Parent/Guardian’s Occupation 1

Parent/Guardian’s Occupation 2

Do the individuals named above have parental responsibility to the named child?

Yes

Do the individuals named above have legal access to the named child?

Yes

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Parent/Guardian’s Occupation

Parent/Guardian Name

Parent/Guardian National Insurance Number

15/30hr code if applicable:

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Please bring in an original copy of child’s birth certificate or passport for manager to verify for Early Years Funding.

Document type and number seen as proof of date of birth:Document type and number seen as proof of date of birth

Document Number

Seen by

Date Seen

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Additional Needs

Known Special Educational Needs/ Any Concerns

Speech & Language Support in Place/ Any Concerns

Does the child have any known Disabilities? If so, please state

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Health

Child’s Doctor’s Name

Address

Telephone

Post Code

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Allergies / Intolerances

Details of any allergies

Details of any intolerances

Please indicate if your child should not be given a particular food due to cultural/religious reasons

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Medication

Is your child receiving any regular medication? If so, please specify

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Additional Information

Are there any festivals or special occasions celebrated in your culture that your child will be taking part in and that you would like to see acknowledged and celebrated whilst he or she is in our setting?

Any other information/details you would like us to be aware of concerning your child

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CONSENT TO EMERGENCY TREATMENT

In the event of my child being taken ill, develops a temperature of 40°C + or sustains an injury whilst in the care of Be Independent Day Nursery, and I/we cannot be contacted, I/we consent to any emergency treatment. For example, call emergency services.

I understand that a full term's notice in writing is required by the first day of the term or the last day of the half term. Should I choose to withdraw my child, in lieu of this a full term’s fees will be charged as per the terms and conditions on the fees policy. All fees to be paid within 7 days of invoice. Late payment fee of 10% of the fee invoice will be charged if the fees fall in arrears. Be Independent Day Nursery withholds the right to refuse to provide childcare in the case of unpaid fees.

Parent/Guardian Signature

Print Name

Date

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