<p> BAYLIS COURT NURSERY SCHOOL OATLANDS DRIVE, SLOUGH, SL1 3HS. TEL: 01753 521917</p><p>APPLICATION FORM </p><p>Child’s full name...... Boy / Girl Date of Birth...... ……… Session preferred: Morning Afternoon Either 8.35 to 11.35 12.35 to 3.35 (Circle or tick)</p><p>Address...... Post code…………… Home Telephone Number...... Mother’s Name...... Mobile/work Tel. No...... ……….. Mother’s National Insurance Number...... Home Address (if different)...... …………. Email address...... Father’s Name...... Mobile/work Tel. No...... ………... Father’s National Insurance Number...... Home Address (if different)...... ………... Email address...... Parental status (please circle) Married, Separated, Divorced, Single, Co-habiting. Please state who has legal parental rights. Name...... Childminders details (if applicable)...... Emergency Contact: Name/relationship...... Telephone Number...... Ethnic Origin: Child...... Mother……...... Father...... (White, Black-African, Black-Caribbean, Black-Other, Indian, Pakistani, Bangladeshi, Chinese, Any other group). How will you be getting your child to nursery? Walk Car Bus Taxi Date of arrival in the United Kingdom ……………………………...... Do you have Refugee status Yes / No Are you seeking asylum in the UK Yes / No Home Language...... Religion...... Other children in the family:- Brothers/Sisters Name Age/Date of Birth School Attended ...... Infant school child will attend ...... Child’s Doctor - Name...... Tel.No...... Health Visitor - Name...... Tel.No...... Have you been supported by any other agencies for any concerns regarding your child? (General health, speech, eyesight, social services, child guidance).</p><p>Please give details...... Does the child have any difficulties as described below? Give details. Allergies / Speech delay / Hearing problems / Asthma / Behaviour / Social problems ………………………………………………………………………………………… Please give any other information which may support us in settling your child or about home/family circumstances which may support grounds for a priority admission...... Is your child on any other nursery school waiting list?...... ……… Which adult will bring and collect your child from school…...... ………... I agree to my child being taken on small outings by qualified staff during school hours; for example, a group visit to a local shop or park. (Parents will be notified separately of any main outings). I agree not to transfer my child to another nursery after a place has been offered, unless I move house and can no longer get here. I understand that if my child does not attend regularly and the place is under used, the the governors may withdraw his/her place.</p><p>Signed...... Parent/Guardian Date...... Please bring your child’s birth certificate with you on the day of admission to nursery school.</p><p>STAFF USE ONLY</p><p>Session offered am / pm</p><p>Group Duck/ Frog </p><p>Member of staff...... ……</p><p>Date admitted...... ……</p>