Child’s Name……………………………………………………………. Surname………………………………………………….

Child’s Middle Name………………………………………………….. Known as………………………………………………..

Gender: Boy Girl Date of Birth…………………………………………….

Address …………………………………………………………………………………………………………………………………..

……………………………………………………………………………….Post Code………......

Home Tel. No………………………………………………………….. Mob. No………………………………………......

Please give details of persons who have parental responsibility

Mother’s Name……………………………………….Surname………………………………………. Priority - 1 2

Address (if different from above)…………………………………………………………………………………………………

Workplace & Tel. No…………………………………………………………………………………………………………………..

Father’s Name………………………………………..Surname……………………………………… Priority - 1 2

Address (if different from above)…………………………………………………………………………………………………

Workplace & Tel. No…………………………………………………………………………………......

Status of Parents (please circle below):

Married Divorced Single Widowed Separated Cohabiting

Other Children in Family

Name / Date of Birth / School

Emergency Contact Name (1)……………………………………………………………………......

Tel. No…………………………………………………………Relationship…………………………………………………………..

Emergency Contact Name (2) ……………………………………………………………………………………………………..

Tel. No…………………………………………………………Relationship…………………………………………………………..

Name of Child’s Doctor …………………………………………Tel. No………………………………………………………….

Address……………………………………………………………….Post Code……………………………………………………..

Mode of Transport (tick one that would normally be used)

Car Bicycle Public Transport Walk

Health Visitor ……………………………………………………. Tel. No………………………………………………………….

Child’s Child’s

Ethnicity…………………………………………………Religion…………………………………………………………………….

Child’s home Language …………………………………………………………………………………………………………….

If you have recently arrived in this country, which country did you arrive from?

……………………………………………………………………………………………………………………………………………….

Date of arrival in this country?......

Are you and your children seeking political asylum in UK?......

Do you have refugee status in the UK?......

Any health or development concerns (speech, eyesight, hearing or general health, allergies

and clinics attended):-

……………………………………………………………………………………………………………………………………………….

……………………………………………………………………………………………………………………………………………….

Any supporting information (home circumstances behaviour problems etc)-

……………………………………………………………………………………………………………………………………………….

……………………………………………………………………………………………………………………………………………….

PREFERRED SESSION – please tick

Morning Session

Afternoon Session

PREFERRED SCHOOL

Baylis Court Nursery School Resource Unit

Chalvey Nursery School Assessment Unit

Slough Centre Nursery School Resource Unit

Please tick the boxes below to confirm your understanding and agreement:-

I understand that my child must always be accompanied to and from the nursery

by a person aged 16 years or above.

I understand that a place is offered t me on the condition that I do not transfer my

child to another Nursery unless I move house to there are extenuating

circumstances that have been discussed with the Head Teacher.

I understand that if my child does not attend regularly, the place may be withdrawn

after extensive discussion with parents.

I agree to my child being taken on outings by qualified staff during school hours.

I agree to my child being seen by a Speech and Language Therapist if necessary,

after discussions with parents.

I understand that my child’s records will be transferred to his/her next school within

the schools’ data system.

Parent’s/Guardian’s Signature ……………………………………………………………. Date ……………………………….

Parent’s/Guardian’s Name …………………………………………………………………………………………………………….