St Mary’s Breakfast and After School ClubRegistration Form

Child’s Full Name / School / Date of Birth
Address:
Home Phone: / Post Code:
Ethnic origin/religion:
Parents/Carers full name / Relationship to Child / Daytime/work tel:

*Please list below all who have parental responsibility for the child (see overleaf)

Name of person with parental responsibility / Relationship to the child

Persons allowed to collect child:

Full Name / Relationship to child / Tel No

Persons NOT allowed to collect child:

Full Name / Relationship to child

Emergency contacts if parents cannot be contacted

Full Name / Relationship to child / Tel No

Please provide details of persons living with the child:

Full name
Relationship
Mother/Father / Full name
Relationship
Aunt, Uncle, Grandparent
Full Name
Relationship / Full Name
Relationship
Full name
Relationship
Brother. Sister / Full name
Relationship
Step Brother, Step Sister
Full Name
Relationship / Full Name
Relationship

This information will be stored in accordance with the Data Protection Act 1998, and treated in confidence and complies with the

requirements of the act.

Please indicate which days you require for Breakfast Club

Monday / Tuesday / Wednesday / Thursday / Friday

Please indicate which days you require for After School Club

Monday / Tuesday / Wednesday / Thursday / Friday
Doctors Name / Surgery & Address / Tel No

Please use the space below to let us know your child’s needs, in order that they can have fun and participate in the activities on offer (eg disability, medical, religious and dietary needs). Please indicate whether your child has an ongoing condition such as asthma, and whether the carry medication or inhalers.

Additional consents: (Please tick the consent you wish to give)

I give consent for:

the use of sun protection cream to be applied in sunny weather
my child to take part in short outing within walking distance of the scheme, eg to a local park or library. I understand they will be accompanied at all times
my child to participate in sporting activities such as swimming, trampolining, tennis, badminton etc whilst supervised appropriately
my child to partake in face painting
My child’s photograph to be used, if required, in displays or publicity
I consent to basic first aid treatment being administered by a qualified first aider and in case of emergency medical treatment/advice being required I consent to the authorised staff member to sign any forms required if a delay in obtaining parent/carers signature could endanger my child’s health
my child to watch PG rated films

Contract for parents/carers to sign:

The details set out in the Information Booklet, together with the details set out here, constitute the contract. The Information Booklet contains details about:

Operating times & feesHealth & SafetyAims & Objectives

Accidents & First AidRegistration ProceduresParental/carers involvement

Notification of absencesChild protectionBehaviour Management

ConfidentialitySpecial NeedsComplaints Procedure

Equal OpportunitiesContact names & numbers

These details, and any amendments and announcements, are also posted on the notice board at the scheme. If you require any additional information or explanation, staff will be pleased to help.

Once your child has been offered a place and attends the club, it is deemed that all parties have read and understood and agreed to abide by all policies and procedures as outlined. This forms a contract.

I agree to the conditions as set out in the contract, including the rule that you will be charged if your child is absent for any reason, and to the additional consents ticked above.

Signed: / Name: / Date:

For the club/scheme, completed by:

Signed: / Name: / Date:
Start Date: / Signed:

* Who has Parental Responsibility?

  • A mother automatically has parental responsibility
  • Where parents are married when the child is born or conceived, they both have parental responsibility
  • Unmarried fathers can acquire parental responsibility by marrying the mother of their child, by a formal agreement with the mother or under a court order (Parental Responsibility Order)
  • If an unmarried father jointly registers the child’s birth with the mother then he will also acquire parental responsibility (this change took effect in December 2003)
  • After divorce, each parent retains full parental responsibility for their children
  • A range of other people, for example grandparents, other relatives, foster carers, or friends can acquire Parental Responsibility under a court order
  • If the court makes a care order the local authority also has parental responsibility