Ballyragget Community Playgroup

Child’s Full Name: ______Boy/Girl______

Date of Birth: ______/______/______Religion: ______

Home Address:

Child’s Nationality: ______Child’s First Language: ______

Date of Commencement: ____/____/_____ Date Ceased Attending: ____/____/__

Parent / Guardian:

Name: ______Name: ______

Address: ______Address: ______

______

Nationality: ______Nationality: ______

First Language: ______First Language: ______

Mobile No: ______Mobile No: ______

Home No: ______Home No: ______

Work No: ______Work No______

Person(s) authorised to collect my child (other than parents and over 18 years of age)

Name: ______Name: ______

Address: ______Address: ______

Contact No ______Contact No ______Other:

Name (1) ______Name (2) ______Name (3) ______Name (4) ______

(If a person is not named in this section, they will be unable to collect your child from the service)

Nominated Emergency Contacts

Name: ______Name ______

Relationship to Child: ______Relationship to Child; ______

Contact Number: ______Contact Number: ______

Personal Details:

Family Doctor: ______

Address: ______

Telephone Number: ______Public Health Nurse ______

Is your family receiving support from a Family Social Worker? Yes No

If yes, please provide their name: ______

IMMUNISATION RECORD (PLEASE ENTER DATE RECEIVED )

AGE WHERE VACCINE DATE RECEIVED Birth Hospital/Clinic BCG(TB) 2 months GP 6 in 1 + PCV 4 months GP 6 in 1 + Men C 6 months GP 6 in 1 + Men C +PVC 12months GP 6 in 1 + PCV 13months GP MMR + HIB 4-5 Years GP /School Special / Additional Needs

Does your child suffer from any medical conditions, illness, special needs, disability and/or allergies?

If yes, please outline details and special requirements: Yes No

Does your child suffer any physical / learning disability?

______

Does your child have any specific dietary/cultural requirements?

Does your child use ‘pet’ language for special comfort toys? Yes No

Name of siblings and /or close personal relationships in your child’s life:

Please outline details and special requirements/needs if any, your child may have (that is not mentioned) Notes provided by parents concerning any of the above are attached to file Yes ( ) No ( ) Parental Consent Form

The Following relates to Policies and Procedures in the Parents Handbook:

1. Emergency Medical Care

I understand that every effort will be made to contact the named guardian or next of kin in the event of an emergency, requiring medical attention. However, if now of these can be contacted, I hereby authorise the service to transport my child to the doctor’s surgery or to the appropriate hospital A & E Department by ambulance or as is necessary and to secure the necessary medical treatment for my child.

Parent / Guardian’s Signature: ______Date: ___/___/____

2. Emergency Medical Treatment

I give Permission for my child to be given appropriate emergency medical treatment in the case of an emergency.

3. First Aid:

I authorise that staff trained in First Aid may administer First Aid to my child as appropriate

4. Antipyretic

I give consent to teething gels and temperature control: medication (Calpol/Nurofen) in accordance with the policy and procedures of the service.

5. Child Illness and Exclusion Policy

I understand that it is in the best interest of my child’s health and welfare and that all other children attending the service to adhere to the services Child illness and Exclusion policy in relation to infections/contagious ailments and to notify the service of any such illness

6. Trip/Outing/Walking Permission I authorise that my child may be taken on outings/walks that may be planned outside the childcare centre grounds on the understanding that the adult/child ratio as recommended by the Insurance Company will be adhered to at all times. I understand that all necessary precautions will be taken to ensure my child’s safety. A trained Firs Aid person will be present on all outings.

7. Permission to Change Clothes

I hereby give permission for my child’s clothing to be changed should the need arise.

8. Photo and Video Permission

I give permission for my child to be photographed or video recorded within the service.

Photographs/Videos may be used for:

1. Child observations and feedback to parents 2. HSE inspection and service evaluation 3. Displays and information. Photos/Videos may be shared with other parents, HSE inspectors and other authorised personnel.

9. Child Observation Permission

Child observations will be used in the service to ensure that the individual needs of children are met through the curriculum and programme. I give permission for child observations to be conducted in the service as outlined in the policy and procedures of the service.

10. (1) Child’s Class :

(2) I give permission for my child to walk home on his/her own at 5.45pm Yes ( ) No ( )

Parent / Guardian’s Signature ______Date ____/____/____

11. Access to Animals/Insects

I give permission for my child to be in contact with or have supervised access to animals or pets. Care will be taken to ensure that the health, safety and welfare of the children are not put at risk.

12. Sun Cream Permission

I give permission for the application of sun cream to my child as outlined in the service Sun Protection Policy.

13. Fees and Payment Policy

Fees are payable weekly and where possible in advance in cash payments. In the case of absences due to illness, family holiday etc fees are still payable as this secures your child’s place in the service. Fees payable are dependent on individual circumstances and will be agreed with the Childcare Manager prior to start date.

I acknowledge the terms and conditions set out in the Fee Policy.

Form completion checklist:

I have supplied all required details for my child and parents/guardians Yes ( ) I have named all person authorised to collect my child Yes ( ) I have provided 2 emergency contact numbers Yes ( ) I have provided details for my family doctor & child immunisation Yes ( ) I have provided any details additional/special needs for my child Yes ( ) I understand, acknowledge & give signed consent to the above policies Yes ( )

14. Parent/Service Childcare Declaration

I will notify management of changes to any of the details in this form. I will give at least two weeks’ notice before I terminate my child’s placement

Manager /Supervisor’s Signature ______Date: __/____/____

This Childcare project is funded by the Irish Government and part-financed by the European Union Structural Funds under the National Development Plan, 2007 – 2013.