DABE Monique

Interinstitutional crèches // Application for admission

Form 1: Information concerning the official or employee of the European institutions

Family name:First name:

Institution: Staff No.:

Status:OfficialOther employee

Occupation:Full-time Part-time ([1]) CCP/CP[2]

Marital status:

Private address / Street and number:
Post code and town:
Country:
Home tel. no.:
Mobile phone no:
Work address / Building:
Office address:
Telephone:
Email address[3]:
Information concerning the child / Family name:
First name:
Date of birth:
Language(s) spoken:

In my capacity as, I hereby apply for the admission of my child for the following date:

I declare that I have read the crèche regulations and that I accept all the terms and conditions set out therein; I have also read the note concerning the protection of personal data. The regulations are also applied if the child is admitted in a private crèche under contract with the European Parliament.

I hereby authorise any emergency measures, including surgical operations, which might be needed as a result of illness or accident during my child’s presence at the crèche.

Luxembourg, .Signature:

Interinstitutional crèches

Application for admission

Form 2: Information concerning your spouse or other person responsible for the child

Family name:First name:

Marital status:

To be completed only if private address is different from that on Form 1

Private address / Street and number:
Post code and town:
Country:
Home tel. no.:
Mobile phone no:

To be completed if the person is also employed by a European institution

Work address / Institution: / ...... European ParliamentEuropean CommissionCourt of JusticeCourt of AuditorsPublications OfficeTranslation Centre
Status: / ...... OfficialOther agent
Occupation: / ...... CCP/CPFull-timePart-time
Staff No.:
Office address:
Telephone:
Email address[4]:

To be completed if the person works outside the European institutions

Work address / Name of employer:
Address of employer:
Occupation: / ...... CCP/CPFull-timePart-time
Telephone:
Email address:

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Interinstitutional crèches

Application for admission

Form 3: Health notes on the child to be admitted to the crèche

Family name:First name:

Gender: F M

Date of birth: Place of birth (town/country): /

Child’s regular paediatrician:

Person to be contacted in an emergency:

Family name / First name / Telephone 1 / Telephone 2

Health information concerning the child

Weight at birth: / Size at birth:
Does the child have: / Please give details if the answer is affirmative
  • apsychomotor deficit: ...... noyes

  • any loss ofhearing: ...... noyes

  • any loss of vision: ...... noyes

  • any allergies to drugs: ...... noyes

  • a tendency to haemorrhage: ...... noyes

  • convulsions: ...... noyes

  • special dietary needs: ...... noyes

  • the need to take medicines on a continuous basis ...... noyes

Has the child had the following illnesses:
Mumps / Measles / Rubella / Scarlet fever
Chickenpox / Whooping cough / Otitis / Pneumonia/bronchitis
Asthma / Hepatitis ([5]) / Tuberculosis / Cutaneous reaction
Any other illnesses to be specified:
Any surgical operations to be specified:
Vaccinations / Dates
DiTePer (diphtheria/tetanus/whooping cough) / 1stbooster:
2nd booster:
3rd booster:
Polio / 1stbooster:
2nd booster:
3rd booster:
HIB (Haemophilus influenzae type b) / 1stbooster:
2nd booster:
Measles
Mumps
Rubella
BCG vaccination
Any other vaccinations: [6]
Any recommendations from parents

Please be advised that due to the large number of children admitted to the crèche and the health risks associated to any collectivity,all children must be vaccinated against the above-mentioned illnesses. Please also note that the crèches service reserves the right to refuse to admit a non-vaccinated child.

Important!

A certificate from the paediatrician certifying that the child:

  1. shows no symptoms of any contagious disease;
  2. has no transmissible ailments and
  3. is not a carrier of parasites, must be attached to the registration documents.

The following mustbe annexed to this:

  1. birth certificate of the child

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Interinstitutional crèches

Application for admission

Form 4: Information concerning children regardedas dependants

Family name / First name / Date of birth / Preschool or school establishment

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[1] Specify the percentage of time spent working (half-time, 3/5, etc.)

[2] CCP = leave on personal grounds, CP = parental leave, or sick leave

[3] Address of the European institutions

[4] Address of the European institutions

[5] If so, please mention the type

[6]Please give details