Slough Children’s Centres 1
Registration Form
Confidential
IF YOU REQUIRE HELP TO COMPLETE THIS FORM,
PLEASE SPEAK TO A MEMBER OF STAFF
Slough Children’s Centres
St Martins Place, 51 Bath Road,
Slough, Berkshire, SL1 3UF
Data Protection:
Under the Data Protection Acts 1984 and 1998, we are required to gain your permission to keep personal details for you and your children on our databases. Slough Children’s Centres may share this information with government and local authority departments and other authorised organisations for administrative, statistical and research purposes. Completing this form and signing it gives us your informed consent.
CHILD’S DETAILS
- Legal First name: ........…..……….………………… Usually Known As: ………………...... …......
Middle name: ………...... ….…………. Surname:………......... …...... ………..
Child’s address:…...... …...... ………...... ……...
…………………………………………………………. Postcode: ….………..………......
Date of birth:..…...../………/……… Gender:Male / Female
NHS Number: ………………………………………... Country of Birth: ………………………………..
Main language spoken at home:.………………………………………………………….....……
Other languages spoken:..…….…………………………………………………………...
Religion:…...…………………...……….………………………………...
Password known only to persons authorised, by you, to collect your child: ……...………………
Please bring your child’s original full birth certificate and proof of address so that we
can take a photocopy for your child’s records.
Please tick the box that best describes your child’s ethnic background.Asian Bangladeshi / Black African / White / Asian Bangladeshi / White British / Chinese
Asian Indian / Black Caribbean / White / Asian Indian / White European / Other
Asian Pakistani / Black Other / White / Asian Pakistani / White Irish / Not Stated
Asian Pakistani Mirpuri / White / Black African / White Other
Asian Pakistani Kashmiri / White / Black Caribbean
Asian Other / White / Chinese
Other Mixed
- If you child requires taking or collecting from school, please complete the following details:
Name of School:...... ……………………………...... ……………………….
Address:…...... …......
Telephone number: …...... …......
Year group:...…...... Class:...…......
PARENT/CARER DETAILS
- First Parent / Carer Details
Title:Mr/Mrs/Ms/Miss/Dr/Other…………………………………Gender:Male / Female
First Name…...... …...………………………………………...... …
Surname…...... …………………………………...... …..
Ethnicity …...... ………………Language...... ………
Date of birth ..…...../………/……… National Insurance Number …………………………….
Address (if different to child)...…......
…………………..……...... Postcode......
Relationship to child…………………………………………………...... ……...
Home telephone number.…………………………………………………………………......
Daytime / work telephone number ……...... ……………………………………………………...….
Mobile telephone number…....……………………..……………………………….……......
E-mail address…....……………………..……………………………….……......
Do you have legal parental responsibility for the child named in this form YES / NO
- Second Parent / Carer Details
Title:Mr/Mrs/Ms/Miss/Dr/Other…………………………………Gender:Male / Female
First Name…...... …...………………………………………...... …
Surname…...... …………………………………...... …..
Ethnicity …...... ………………Language...... ………
Date of birth..…...../………/………National Insurance Number …………………………….
Address (if different to child)...…......
…………………..……...... Postcode......
Relationship to child…………………………………………………...... ……...
Home telephone number.…………………………………………………………………......
Daytime / work telephone number ……...... ……………………………………………………...….
Mobile telephone number…....……………………..……………………………….……......
E-mail address…....……………………..……………………………….……......
Do you have legal parental responsibility for the child named in this form YES / NO
Does anyone else have legal parental responsibility for the child named on this form?
YES / NO
If your answer is yes then you must complete their details on the next page.
SIGNIFICANT OTHERS THAT HAVE LEGAL PARENTAL RESPONSIBILITY
Only to be completed if anyone other than the two named individuals above has Legal Parental Responsibility for the child named on this registration form.
- Details of Individual with Legal PR
Title:Mr/Mrs/Ms/Miss/Dr/Other…………………………………Gender:Male / Female
First Name…...... …...………………………………………...... …
Surname…...... …………………………………...... …..
Ethnicity …...... ………………Language...... ………
Date of birth..…...../………/………National Insurance Number …………………………….
Address (if different to child)...…......
…………………..……...... Postcode......
Relationship to child…………………………………………………...... ……...
Home telephone number.…………………………………………………………………......
Daytime / work telephone number ……...... ……………………………………………………...….
Mobile telephone number…....……………………..……………………………….……......
E-mail address…....……………………..……………………………….……......
Date PR awarded …………………………………… Evidence copied for file: YES / NO
CHILD’S FAMILY
- People that live in the same house with your child (not named above) and including other children:
First Person
First name:…...... …………………….Surname:….…......
Date of Birth:…...... …………………….Relationship to child: ......
Second Person
First name:…...... …………………….Surname:….…......
Date of Birth:…...... …………………….Relationship to child: ......
Third Person
First name:…...... …………………….Surname:….…......
Date of Birth:…...... …………………….Relationship to child: ......
Fourth Person
First name:…...... …………………….Surname:….…......
Date of Birth:…...... …………………….Relationship to child: ......
COLLECTION FROM THE CHILDREN’S CENTRE
Please note that:
- All children must be collected by the child’s main carer or another responsible person.
- You must name an alternative person to collect your child in the event you are not able to.
- You must notify us if someone, other than the usual collector, will be collecting your child.
Please tell us who can collect your child from the Children’s Centre and in the event of an emergency, other than the parent or carers already named on this form.
First Person Details
Name ……………………..…………………..…....…...…......
Address (if different to child above)...... …...... …......
…………………..……...... …...... …………...... ……......
Relationship to child...... ………......
Contact number during service hours...... …………………………………………...………….
Is the above person over 18 years old? YES / NO
Second Person Details
……………………………………………………..…....…......
Address (if different to child above)...... …...... …......
…………………..……...... …...... …………...... ……......
Relationship to child...... ………......
Contact number during service hours...... …………………………………………...………….
Is the above person over 18 years old? YES / NO
If either of the individuals named above are under the age of 18 years you must sign the disclaimer below to authorise the individual, under the age of 18 years, to collect your child.
I deem (name of individual under 18 years)……………………………………………… responsible to collect my child from the Children’s Centre and to care for my child. I can confirm that the individual is above 16 years of age.
Signed: ……………………………………… Print: ……………………………………………
Date:………………………………………
CHILD’S HEALTH, MEDICAL AND DIETARY NEEDS
- Child’s Doctor’s Details
Doctor’s surgery name...... ……………...... …...... …...
Address of surgery...... …...... ……
Doctor’s telephone number...... ………………………………………………..…….….
Named Health Visitor (if known)...... ………………………………………………..…….….
- Details of immunisations that your child has been given (please tick and state date)
Immunisation / Tick / Date given / Immunisation / Tick / Date given
Diphtheria / Measles, mumps, rubella (MMR)
Tetanus / Polio
Whooping cough / Flu Vaccination
BCG / Other
- Details of medical conditions and special needs. Please give us as much information as possible to ensure that your child’s needs are met whilst he/she is in our care.
Description / Tick / Further details, including any medication taken, additional support required, other agencies involved etc.
Anaphylaxis
Asperger’s Syndrome
Asthma
Autism
Diabetes
Eczema
Emotional and behavioural difficulties
Epilepsy
Hearing impairment
Learning difficulties
Mobility or physical impairment / disability
Speech impairment
Visual impairment
Other – please state
- Child’s Dietary Requirements
Please give as much information as possible so we can ensure your child’s dietary needs are met.
Food Allergen Group / Allergy / Intolerance / Details of Allergy or Intolerance, including medicationCelery
Egg
Fish
Gluten
Lupin
Milk
Mustard
Nut
Peanuts
Sesame Seeds
Shell Fish
Soya
Sulphur Dioxide
Wheat
Dietary Requirements / Tick / Further information
Able to eat all meats (non halal)
Able to eat all meat (non halal)except beef
Able to eat all meat (non halal) except pork
Vegetarian and can have fish and egg
Vegetarian
Vegan
Other (please state)
As a service we take the health, safety and welfare of our children very seriously. We would therefore like to create and use a placemat at mealtimes that will make it clear which foods your child should not be given. The placemat will include your child’s name and photo, and a brief description about their food preferences. E.g. I’m vegetarian, I can’t eat eggs
Print: ………………………………………
Date:……………………………………… Sign: ……………………………………………
LINKS TO OTHER SERVICES
Slough Children’s Centres wants to ensure that you and your child receive the services to which you are entitled. On page12 we ask you for permission to share information with other agencies.
Service / Are you or your child involved with this service at present? If so, please tick the box and give details.Child / First Parent / Carer / Second Parent / Carer
Child and Adolescent Mental Health Service
Adult Mental Health Service
Child Development Centre (UptonHospital)
Slough Children’s Services Trust (Social Care)
Early Help Team
Targeted Support Worker
Paediatrician
Speech and Language Therapy Service
Health Visiting Service
Job Centre Plus
Midwifery Service
Police and Probationary Service
School Nursing
Family Nurse Partnership
Housing Services
Domestic Abuse Services
Special Educational Needs Services
Physio Services
Occupational Therapists
Sensory Consortium
Other: ………………………..
Other: ………………………..
FURTHER INFORMATION
At Slough Children’s Centres we want to ensure that you and your child receive the services that you and your family need. Please help us to continue to review the services we currently offer.
Please tick all that apply / You / Second parent /carer
Under 20 years old
Between 20 and 24 years of age
Lone parent caring for child / children under 18
Unemployed
Receiving income related benefits
Visa / No recourse to public funds
Working less than sixteen hours a week
Working over 16 hours a week
Working over 30 hours a week
Full time student
Part time student
Which services are you interested in? / For you / For second parent/carer / For your children
Help to learn English
Help with literacy, numeracy or other life skills (give details)
Help with other adult learning (give details)
Family learning (give details)
Help to return to work
Information about benefits and tax credits
Health services
Midwifery services
Support during pregnancy (please give the baby’s due date)
Support as a first time mother or father
Support for children with special needs and disabilities
Support for speech and language development
Help with managing children’s behaviour
Help with difficult family relationships
Other (give details)
Other (give details)
GENERAL and MEDICAL CONSENTS, TERMS and CONDITIONS
General consents - please tick as appropriate
- I give permission for my child to watch occasional U certificate videos / DVDs or children’s television to enhance my child’s learning experience.
- I give permission for my child to be photographed or filmed while he / she attends the Children’s Centre. This will be for the purpose of staff training and to contribute to my child’s All About Me Book, which I will be given when my child leaves the Children’s Centres.
- I understand that Slough Children’s Centres may use the photography or filming for a minimum period of 5 years for publicity, marketing or training purposes. After this time, I may withdraw my consent in writing.
Medical consents (please tick)
I consent to any emergency medical treatment necessary. I authorise the staff at the Children’s Centre to sign any written form of consent required by the hospital authorities if the delay in getting my signature is considered by senior medical staff to endanger my child’s health and safety.
Use of products at the Children’s Centre
We will provide and use a number of products in our Children’s Centres. Please tick the relevant boxes below to show that you are happy for us to use these for your child.
Children using nappies only / Tick / All children / TickAntiseptic cream for nappy rash / Hypoallergenic plasters
Baby wipes / Non-alcoholic wipes for cleaning cuts and grazes (used instead of water only when children are on outings or being escorted from schools to the setting)
Disposable nappies / Sun protection cream suitable for children
Walking services(please tick and complete details as appropriate)
I give permission for my child to be escorted on foot from …………………………………………… (name of school) to ………………….……………….. (name of setting) at the start and / or end of their school day.
Bookings
- You should place your booking by completing a booking form for the dates that you require. Forms are available at the Children’s Centre.
- We will only accept a booking form if it has been signed by the person who has legal parental responsibility for the child named on the form.
- We accept bookings monthly in advance. A timetable of the booking dates is available at the setting.
- We recommend that you place bookings for longer periods than one month in order to reserve your childcare place. If you have booked for a longer period, we will invoice you each month within the first 10 days of the preceding month (see timetable).
- We will not hold a place open for your child from one period to the next if we have not received a signed booking form showing the relevant dates for each period and the correct payment for each period.
- Please note that bookings are only secured by payment and we operate a first come first served allocation process.
Fees Paid by Parents
- For new customers, payment must be made in advance on the same day as the booking is made. We may request that your first payment covers up to 42 days, depending on the date of your child’s first session. Settling-in sessions, if required, will be arranged for your child AFTER your payment has been received. If you decide not to take up your place prior to your child’s start date, if it falls outside of the 28days notice we will not refund your payment.
- Thereafter, each subsequent payment must cover at least the next 28 to 31 days, depending on the month. We will only be able to allocate childcare places and accept repeat bookings if we have received the correct fee at the correct time.
- Wemust receive your bookings and payment no later than the dates shown on the timetable provided by yourChildren’s Centre. If you have not received this timetable, please speak to your Early Years Manager or Deputy Early Years Manager.
- If you have booked for a longer period than one month, an invoice will be ready for you to collect within the first 10 days of the preceding month to give you time to make your payment.
- Late payment will lead to your bookings being suspended until full payment has been received for the period due. There will be a charge of £30 to reinstate your bookings if they have been suspended due to non-payment of fees. Persistent late payment will lead to your bookings being cancelled permanently. We will not reinstate bookings that have been cancelled permanently.
- Please note, we have waiting lists at all our childcare settings. If you do not keep your bookings and payments up to date, you run the risk that your place will not be available when you need it.
- Cancellations can only be refunded if 28 calendar days notice is given, in writing on a changes to bookings form (available in reception). If you notify us with less than 28 days notice, your child is absent or sick you will still be charged the full amount for the sessions you have booked.
Charges for Late Collection of your Child
If you have become unavoidably detained, you should arrange for your emergency collector to collect your child and you should call the setting to inform staff of the situation. Persistent late collection will lead to a charge. For every 5 minutes you are late, we will charge you 50% of the average hourly rate applicable to your child. This must be paid before your child is able to resume attendance at the setting. Continuous late collection could result in the suspension of all bookings.
Children’s Centre Closures
We close all our settings for a number of days each year to allow for staff training, planning, preparation and building maintenance. We also close for the 8 annual public holidays that apply in the United Kingdom. Full details of our operating dates are available from all of our Children’s Centres. We do not charge for planned closures.
We do not accept responsibility for any loss, arising directly or indirectly, as a result of the Centres having to close for any reason outside our control. Fees will not be refunded for such closures. The Centres will only be closed after all reasonable endeavours have been made to provide a service. In these circumstances, it may be that a service will be offered on an alternative site.
Information sharing agreement (please tick)
Under the Data Protection Acts 1984 and 1998, I give permission for setting staff to share relevant information with and receive information from other agencies regarding my child. I understand that I will be informed when information is shared and that this information will remain confidential between the setting staff and the agencies involved and will only be used in the best interests of my child to support his / her progress and promote his / her welfare. I undertake to keep the setting informed of the agencies and services involved with my child.
Parental responsibility (please tick and complete details as appropriate)
I confirm that I have completed this registration form as the legally responsible
parent or carer for (name of child) …………………………………………………......
Terms and conditions (please tick)
I have read and agree to abide by the terms and conditions of the Children’s Centre as stated above.
Signature of parent/carer...... …...... Date ...... /...... /.…......
Full name in block capitals...... …......
Safeguarding Statement
Safeguarding of children is defined as per Slough Children’s Centre Safeguarding Policy:
-protecting children from maltreatment
-preventing impairment of children’s health or development
-ensuring that children grow up in circumstances consistent with the provision of safe and effective care; and
-taking action to enable all children to have the best outcomes
Our view of effective safeguarding arrangements should be underpinned by two key principles:
-Safeguarding is everyone’s responsibility: for services to be effective each professional and organisation should play their full part; and
-A child-centred approach: for services to be effective they should be based on a clear understanding of the needs and views of children.
Our Commitment
The highest priority for all Slough’s Children’s Centres is to keep children safe and protect their wellbeing. All staff and partner agencies working together at the Centres recognise and understand their duty to cooperate with each other and you as parents to safeguard and promote the welfare of children.
Registration Form May 2016