<p> REGISTRATION FORM</p><p>CHILD’S PERSONAL DETAILS</p><p>First Name</p><p>Last Name CHECKED BY Date of Birth</p><p>Gender</p><p>Home Address</p><p>Mobile Number Home Phone Number of the main carer</p><p>Postcode and name of the London CHECKED BY Borough</p><p>Email Address (please print). This will be used for correspondence</p><p>Language(s) spoken at home</p><p>Religion</p><p>Special Dietary Requirements</p><p>Names of His/ Her Siblings</p><p>CHILD’S ETHNICITY– Please circle one from the below list</p><p>Afghan Greek Cypriot Pakistani White and Black Caribbean</p><p>African Asian Gypsy/ Roma Portuguese White and Indian Albanian Indian Serbian White and Pakistani</p><p>Bangladeshi Iranian Sri Lankan – Sinhalese White Eastern European</p><p>Black - Ghanaian Iraqi Sri Lankan – Tamil White Other Black - Nigerian Italian Turkish White Western European</p><p>Black - Caribbean Japanese Turkish Cypriot Any other Black background</p><p>Bosnian Kosovan White British Any other Ethnic background</p><p>Chinese Kurdish White Irish Any other mixed background</p><p>Croatian Nepali White and Asian Traveller of Irish Heritage</p><p>Greek Other Asian White and Black African Any other White Background PARENT/ CARER CONTACT DETAILS (BOTH SECTIONS MUST BE FILLED) PARENT / CARER 1 DETAILS</p><p>Name of the person with whom the child resides – Main Carer CHECKED BY Date of Birth</p><p>Has this person got parental responsibility?</p><p>Relation to the Child</p><p>Country of Origin</p><p>Email Address (please print)</p><p>Profession</p><p>Work Address and Phone Number</p><p>National Insurance Number/ NASS reference – asylum seekers only</p><p>PARENT / CARER 2 DETAILS</p><p>Name </p><p>Their Date of Birth</p><p>Has this person got parental responsibility?</p><p>Relation to the Child</p><p>Country of Origin</p><p>Email Address (please print)</p><p>Profession</p><p>Work Address and Phone Number</p><p>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)</p><p>Full Name Relation to the Phone Number Photos Child Included DOCTOR DETAILS</p><p>Doctor’s Name</p><p>Surgery’s Name</p><p>Surgery’s Address </p><p>Surgery’s Telephone Number</p><p>Professionals involved (if any) with the child (Name, Contact Details </p><p>IMMUNISATIONS</p><p>Has your child had any of the following? Please give details:</p><p>AGE DUE IMMUNISATION Yes / No Date / Details</p><p>8 weeks Diphtheria/ Tetanus/ Whooping Cough/ Polio/ Hib</p><p>PCV</p><p>12 weeks Diphtheria/ Tetanus/ Whooping Cough/ Polio/ Hib</p><p>Men C</p><p>16 weeks Diphtheria/ Tetanus/ Whooping Cough/ Polio/ Hib</p><p>Men C + PCV</p><p>12 – 18 MMR (Measles, Mumps, Rubella) months Hib/ Men C + PCV</p><p>Diphtheria/ Tetanus/ Pertussis 3 – 5 Years Polio</p><p>MMR</p><p>Other (Hep B, BCG, etc) NURSERY DETAILS</p><p>MON TUES WED THURS FRI Days and Times agreed for the child to attend nursery </p><p>Registration Fee £30 non-refundable</p><p>Notice of termination 6 weeks’ notice period required to both parties (one half-term)</p><p>Fees We have many flexible options. Please discuss with the nursery manager to see what best suits your needs</p><p>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</p><p>The children have to bring in their own  Nappies (if necessary) Any other details  At least one change of clothes  Healthy packed lunches.</p><p>PARENT / CARER DECLARATION Please tick each bullet box if you agree/ consent</p><p> 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.</p><p>Signed ………………………………………………………… Date …………………… Name ………………………………………………………….</p>