CHILD S ETHNICITY Please Circle One from the Below List

REGISTRATION FORM

CHILD’S PERSONAL DETAILS

First Name

Last Name CHECKED BY Date of Birth

Gender

Home Address

Mobile Number Home Phone Number of the main carer

Postcode and name of the London CHECKED BY Borough

Email Address (please print). This will be used for correspondence

Language(s) spoken at home

Religion

Special Dietary Requirements

Names of His/ Her Siblings

CHILD’S ETHNICITY– Please circle one from the below list

Afghan Greek Cypriot Pakistani White and Black Caribbean

African Asian Gypsy/ Roma Portuguese White and Indian Albanian Indian Serbian White and Pakistani

Bangladeshi Iranian Sri Lankan – Sinhalese White Eastern European

Black - Ghanaian Iraqi Sri Lankan – Tamil White Other Black - Nigerian Italian Turkish White Western European

Black - Caribbean Japanese Turkish Cypriot Any other Black background

Bosnian Kosovan White British Any other Ethnic background

Chinese Kurdish White Irish Any other mixed background

Croatian Nepali White and Asian Traveller of Irish Heritage

Greek Other Asian White and Black African Any other White Background PARENT/ CARER CONTACT DETAILS (BOTH SECTIONS MUST BE FILLED) PARENT / CARER 1 DETAILS

Name of the person with whom the child resides – Main Carer CHECKED BY Date of Birth

Has this person got parental responsibility?

Relation to the Child

Country of Origin

Email Address (please print)

Profession

Work Address and Phone Number

National Insurance Number/ NASS reference – asylum seekers only

PARENT / CARER 2 DETAILS

Their Date of Birth

Has this person got parental responsibility?

Relation to the Child

Country of Origin

Email Address (please print)

Profession

Work Address and Phone Number

PEOPLE AUTHORISED TO COLLECT THE CHILD (WITH PHOTOGRAPHS) (Please give details of at least 2 in case of emergencies. The authorised people have to be above 16 years of age)

Full Name Relation to the Phone Number Photos Child Included DOCTOR DETAILS

Doctor’s Name

Surgery’s Name

Surgery’s Address

Surgery’s Telephone Number

Professionals involved (if any) with the child (Name, Contact Details

IMMUNISATIONS

Has your child had any of the following? Please give details:

AGE DUE IMMUNISATION Yes / No Date / Details

8 weeks Diphtheria/ Tetanus/ Whooping Cough/ Polio/ Hib

Men C + PCV

12 – 18 MMR (Measles, Mumps, Rubella) months Hib/ Men C + PCV

Diphtheria/ Tetanus/ Pertussis 3 – 5 Years Polio

Other (Hep B, BCG, etc) NURSERY DETAILS

MON TUES WED THURS FRI Days and Times agreed for the child to attend nursery

Registration Fee £30 non-refundable

Notice of termination 6 weeks’ notice period required to both parties (one half-term)

Fees We have many flexible options. Please discuss with the nursery manager to see what best suits your needs

If your child is not collected on time, then a charge of £1 will be made for every minute from the time that your child finishes nursery Late Charges

The children have to bring in their own  Nappies (if necessary) Any other details  At least one change of clothes  Healthy packed lunches.

PARENT / CARER DECLARATION Please tick each bullet box if you agree/ consent

 I have no objection to:  Pictures being taken of my child for the following purposes (please tick as appropriate):  Nursery records  Provision to ourselves  Child’s own personal records  Some pictures may be published on the nursery’s website and other marketing publications  Pictures of my child in group photos may be distributed among the children in that photo.  The nursery staff members administering medication and contacting the emergency services if required, prior to me reaching the point of incident/ accident.  The nursery taking my child on small trips (within 1 mile radius) around the nursery setting to enable me child’s experiences to improve his/ her early learning Goals.  I understand that specific permission will be sought from me for photographs to be taken for any other purpose.  I further confirm that I have been shown the Policies and Procedures of the Nursery and agree to them (the staff) caring for my child within the terms stated therein. I also have been told that they are available at all times near the signing in sheet, if I should require them at a later stage.  I also take responsibility to keep the nursery informed if my personal details/ circumstances change.  I consent for the involvement of the EYIS Team/ Area SENCO, if deemed necessary by the nursery staff team, however specific permission will be sought before other agencies or professionals are involved.

Signed ………………………………………………………… Date …………………… Name ………………………………………………………….