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HOLIDAY PLAY SCHEME REGISTRATION FORM
By completing this form you register your interest in a place at Coin Street Holiday Play Scheme programme. You are not guaranteed a place until you have specifically been contacted and notified.
Date (DD/MM/YY):Time (HH/MM):
CHILD DETAILS
First name: Last name:
Date of birth (DD/MM/YY):
Current age:
Gender (please circle): MaleFemale
Ethnicity* (Please circle):
White British / Greek Cypriot / Mixed White and African / Other Black African / Other AsianWhite Irish / Turkish / Mixed Other / Any other Black background / Latin/South/Central
White Irish Traveller / Turkish Cypriot / Black Caribbean / Indian / Kurdish
White Western Europe / Kosovan / Nigerian / Pakistani / Prefer not to say
White Eastern Europe / Gypsy/Roma / Somali / Bangladeshi / Other (please specify):
White Other / Mixed White and Black African / Sierra Leonian / Chinese
Greek / Mixed White and Caribbean / Ghanaian / Vietnamese
School attending:
Postcode:
*Our Children's Centre funding requires us to provide statistical information about the ethnic origin of children using our services. We will not use this data for any other purposes.
All personal information given on this form will be held and used in accordance with the Data Protection Ac t 1998.
MOTHER’S/GUARDIAN’S DETAILS
Title (please circle): MissMrMrs MsOther (please specify):
First name:Last name:
Address:
Post code:
Home telephone:Work telephone:
Mobile:
E-mail:
Relationship to child/children:
Borough (please circle): Lambeth SouthwarkOther (please specify):
FATHER’S/GUARDIAN’S DETAILS
Title (please circle): MissMrMrs MsOther (please specify):
First name:Last name:
Address:
Post code:
Home telephone:Work telephone:
Mobile:
E-mail:
Relationship to child/children:
Borough (please circle): Lambeth SouthwarkOther (please specify):
EMERGENCY CONTACTS (this cannot be any of the persons names above)
Emergency contact 1
Name:Phone number:
Relationship to child:
NON-CONTACT (anyone who is NOT allowed to collect or have contact with the child)
Name:Phone number:
Relationship to child:
If you have named a person as non-contact, please ensure that this is discussed with the Senior Administrator. You will be asked to share the relevant paperwork where appropriate.
HEALTH INFORMATION
Please confirm any diagnosed or suspected health concerns your child may have, such as asthma or diabetes. Together we will devise a plan to ensure your child receives appropriate care.
Does your child have any allergies? (Please circle):YesNo
If yes, please specify
Does your child have any dietary requirements? (Please circle):Yes No
If yes, please specify
Does your child require any special skin care? (Please circle):Yes No
If yes, please specify
Does your child have any distinguishing marks, such as Mongolian Blue Spot?
(Please circle): YesNo
If yes, please specify
Please note we do not administer any medication unless it has been specifically prescribed and the relevant forms have been signed.
Terms and conditions of Holiday Play Scheme placement
In these terms and conditions, "Holiday Play Scheme", and "we" and "our" means Coin Street
Centre Trust, situated at Coin Street neighbourhood centre. "Parents" or "you" means the parents orguardians or the person responsible for any child registered at Holiday Play Scheme; and "children" or "child" means any child that has been registered at Holiday Play Scheme.
In order to register your child with Holiday Play Scheme parents must fill in the registration form, (available on request). Please note that a registration fee is not required and children registered with the holiday play schemes automatically stay on our register each term. Holiday play scheme children remain registered but do need to book for each play scheme by completing a form and make all payments in advance of the booking.
Registration fee
Once CSOSC has notified you that your child has secured a booking, payment must be made in full before the start of each holiday club period. Payment is required and will not be refunded irrespective of attendance including absence due to illness, family holidays or preference, however caused as this has prevented another child attending.
Cheques can be made payable to 'Coin Street Centre Trust' or 'CSCT'.
Please inform us as soon as possible if your child is going to be absent and of any infectious illness so we can warn others. Please keep your child at home if they have been sick, had diarrhoea or have conjunctivitis for at least 24 hours after the last bout or until medication has been administered for at least 24 hours depending on the illness - please contact the office for specific instructions. We reserve the right to send home any child if such an action is deemed to be in the best interests of that child or the other children. The registration form asks for contact details in case of accident/illness, parents/carers must ensure that we know of any change in marital status, address or telephone/mobile numbers this is for your child's emotional wellbeing and in case we have to contact you in an emergency and call social services.
Late drop offs and collections
Parents must ensure that children are dropped off by 9:30am unless otherwise advised, as this is often the time children leave for trips. If you are not in by this time we will give you directions as to where to find the group when it is possible to join them. We will not offer other forms of childcare when children are late.
Please note that it is important for the children and for our staff that children are collected promptly. We appreciate that delays can sometimes be unavoidable, but to cover our costs we do reserve the right to charge £5.00 per 10 minutes caring for children when parents are late. If we are unable to contact a parent by 6.30pm we will follow our non collection of child policy which is displayed in the settings. If a child is repeatedly collected late than there is a risk of forfeiting their place. This decision will be at the discretion of Holiday Play Scheme.
In the event of any fees remaining unpaid, parents breaching any of these terms and conditions or we deem this action to be necessary in the interests of the other children or of Holiday Play Scheme, we reserve the right to suspend or terminate a child's place.
Upon registration of a child at Holiday Play Scheme, Holiday Play Scheme and the staff employed will act in Loco Parentis for the duration of the time that the child is in our care, both on and off the premises, until a parent or chosen representative collects the child. In the case of any illness, accident or emergency, Holiday Play Scheme shall have the right to take such actions as are deemed appropriate, including hospitalisation if necessary even if the parents have not yet been informed.
I confirm that I have read, understood and agree to the above terms and conditions. I certify that the information stated is true and correct to the best of my knowledge. I understand that further enquiries may be made at the discretion of the Coin Street family & children's centre. (Please tick to confirm)
PERMISSIONS LIST
Consent A: Application of sun cream
I hereby give permission for the application of sun cream supplied from home.
THIS MUST BE CLEARLY LABLED.
Consent B: Visits to local places of interest
I hereby give permission for our child/children to be taken on planned outingsorganised and approved by Coin Street family & children's centre.
Consent C: Portfolio photography
I hereby give permission for our child/children's photo to be taken and displayed/used within the children centre.
Consent D: Promotional photography
I hereby give permission for our child/children's photo to be taken as stated inthe questionnaire and displayed/used for promotional purposes if needed.
Consent E: Face paint
I hereby give permission for our child/children's to have face paints applied.
Consent F: Travel
I hereby give permission for our child/children's to travel by public transport/coach.
KEEP UP TO DATE
I would like to sign up to the Coin Street e-list to keep up to date with free and local events and activities (please circle): Yes No
IMPORTANT – PLEASE READ THE FOLLOWING BEFORE SUBMITTING THIS FORM
YesIgiveconsentformychild/children tobephotographed/filmedforeducationinformationpurposes
YesIgiveconsentformychild/childrentobephotographed/filmedforpromotionalpurposes
No, Idonotconsentformychild/childrentobephotographed/filmed
I confirm that I have legal responsibility for all children listed on this form and have filled in this form with information correct to the best of my knowledge (please tick to confirm)
PLEASE NOTE: Once your booking has been confirmed, you cannot cancel or make changes to the requested dates of the programme.
Please post or deliver your booking form to the address below for the attention of Nursery Administrator, or email