Thurrock Council

Children's Centre Registration

use BLOCK CAPITALS if completing this form by hand

Data Protection Act
The information you have given on this form will be held confidentially on a secure data base and accessed only by Thurrock Council, partner organisations and other Children’s Centres commissioned by Thurrock Council. This information will be used for statistical purposes and to inform you about activities, resources, and services that are available from Children’s Centres and its partners which include education, careers, health and social care. Personal data in this form may be used in accordance with Thurrock Council’s notification under the Data Protection Act 1998 and will be kept for seven years before being securely disposed of. To comply with statutory and government requirements,data will be disclosed to external agencies such as (but not exclusively): NHS, care agencies, Policy of Courts. Thurrock Council will not disclose any personal information to any other third parties, except where required by law, without the express consent of the data subject.

Parent/Carer details

Parent/Carer 1 / Parent/Carer 2
First Name:
as on birth certificate
Surname:
as on birth/marriage certificate
Address:
Postcode:
Home phone number:
Mobile phone number:
Email address:
Date of birth
Are you under 19? / Yes:No: / Yes:No:
Relationship to child:
What is your marital status:
Are you: / Birth parent
Foster parent
Adoptive parent
Extended family / Birth parent
Foster parent
Adoptive parent
Extended family
Are you a lone parent: / Yes:No: / Yes:No:
Are you currently pregnant?
If yes, please give your
expected due date. / Yes:No:
Due date: / Yes:No:
Due date:
Your employment: / Full time
Part time
Under 16 hours
Unemployed / Full time
Part time
Under 16 hours
Unemployed
Please list any benefits you are claiming
Are you currently in education or training? / Yes:No: / Yes:No:
What is your level of qualification? / No qualifications
Level 1
Level 2
Above level 2 / No qualifications
Level 1
Level 2
Above level 2
Do you consider you have a disability or special need?
If yes, please give details. / Yes:No:
/ Yes:No:
Do you have any identified mental health issues? / Yes:No: / Yes:No:
Do you have any problems with drugs or alcohol? / Yes:No: / Yes:No:
Are you a smoker? / Yes:No: / Yes:No:
Do you have asylum seeker status? / Yes:No: / Yes:No:
Are you serving in the armed forces? / Yes:No: / Yes:No:
Is either parent currently serving a custodial sentence? / Yes:No: / Yes:No:

Child details

Child 1 / Child 2
First name:
as on birth certificate
Surname:
as on birth certificate
Date of birth:
Gender:
Birth weight:
Was your child breastfed? / Yes: No:
if yes, what age was the child when you stopped? / Yes: No:
if yes, what age was the child when you stopped?
Does your child attend school or pre-school or nursery, or are they looked after by a childminder?
Do you consider your child to have any disability or special need? Please give details.
Name of GP or surgery: / Name of family health visitor or practice: / Name of any other professional support you receive:
Ethnicity / P/C / P/C 2 / C1 / C2 / P/C 1 / P/C 2 / C1 / C2
White – British / Black or Black British – Caribbean
White – Irish / Black or Black British – African
White – Traveller / Any other Black Background
White – Traveller of Irish Heritage / Mixed – White and Asian
White – Other / Mixed – White and Black African
Asian or British Asian – Indian / Mixed – White and Black Caribbean
Asian or British Asian – Pakistani / Any other mixed background
Asian or British Asian – Bangladeshi / Any other ethnic group
Any other Asian Background / Unknown
Chinese / Do not wish to be recorded
What is your home language?
Do you need an interpreter? / Yes:No:

I understand the information recorded on this form will be stored electronically and used solely for the purpose of providing services to me and my child/children. I accept responsibility for the information I have provided about a partner, which will also be stored electronically and used to provide services to me and my children.

Signature
Print name
Date
Are they any specific services you need?