| Personal Details | |||
| Name of Child | Telephone | ||
| Gender | Date of Birth | ||
| Religion | Date of Entry | ||
| Address | |||
| Periods requested | |||
| Brothers and Sisters? |
|
Names | |
| Medical Details | |||
| Doctor's Name | Telephone | ||
| Address | |||
| Health Visitor | Telephone | ||
| Address | |||
| Immunisations - circle | MMR | Illnesses - circle | Measles |
| Polio | German Measles | ||
| Other : | Mumps | ||
| Chicken pox | |||
| Health Problems | Whooping Cough | ||
| Food/drink to avoid | Scarlet Fever | ||
| Other Information | |||
| Family Details | |||
| Mother/Guardian | Father/Guardian | ||
| Telephone | Telephone | ||
| Business Address | Business Address | ||
| Emergency Contact | Telephone | ||
| Address | |||
| Consents | |||
|
In the event of a medical emergency my child will be
taken to hospital by a qualified member of staff
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Qualified staff may administer first aid to my child
on the premises
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CCTV monitoring and recording operates in the
facility and parents/guardians will be granted password protected internet
access to view the room their child is in and the grounds
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My child will be taken on local outings by staff including the park, library, etc
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I agree to abide by the terms and conditions of
Mossley Hill Child Care Limited.
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Deposit paid £ , will be refunded at
termination of place conditional on 4 weeks notice being given. Photograph of your child will be taken for the use of wall displays and display boards |
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| Signature of Parent/Guardian |
Date : |
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