Additional Information s3

Additional Date :

Information Start Date End Date If you have any further information that you feel would be helpful in caring for your child, please give details. For example:- Pet Name, Name of Terms & Conditions Coco’s Childcare Siblings, Comforters 1. Payment of fees start with effect of the starting ‘Rathengle’ date written on the registration form. 114 Mt.Merrion Ave. 2. One month’s written notice must be given when canceling a Creche Place. Blackrock, Co.Dublin 3. No fees are refundable if child leaves earlier 01 283 3140 than notice date.

4. All fees are paid one month in advance. Registration Form

5. An interest charge of 5% will be added onto Child’s Name : late payment of fees. Child’s Address : 6. The registration fee of 100 euro is non- refundable.

Type of care We have read and understood these conditions and are in agreement with them. Home Tel No :

required Date of Birth :

Please specify below Signed : Mother’s Name : [ Father ] Mother’s Work Address :

Signed : Work Tel No : [ Mother ] Mobile No : Email No:

Father’s Name : Father’s Work Address :

All infectious diseases must be reported Email No: immediately to the nursery for the sake of the Work Tel No : other children, staff and parents Mobile No : Has your child had any: Name and Address of Person who collects child [ unless Nursery is otherwise informed ] Immunisations & Vaccinations Allergies Name : Address : Has your child been immunised against : Dietary Requirements Please circle as appropriate

B.C.G Yes No Sight / Speech / Hearing Defects Home Tel No : Date Mobile No : Diphtheria Yes No Whom to contact in case of emergency Date Relative / Friend Tetanus Yes No Is your child on any form of medication, if so Date Name : Name Medication, Dosage times and Quantities Address : Whooping Cough Yes No Reason for Medication? Date

Polio Yes No Name of medication Home Tel No : Date Mobile No : Tuberculosis Yes No Dosage Times Has your child suffered From : Date Please circle as appropriate MMR Yes No Quantities Date Chicken Pox Yes No Meningitis Yes No Mumps Yes No Date

Scarlet fever Yes No HIB Yes No Date Family Doctor Other[s] Surgery Address

Tel No