Nursery / Breakfast club / Out of school club / Playscheme
Date received / Date due to start / Date started / Birth certificate seen

(Staff use only)

REGISTRATION FORM

PRIVATE & CONFIDENTIAL

Family details

Name of Child: ………………………………………………………………………………………………………… M/F

Name Child is known by:………………………………………………………………………………………………………………………..…

Date of birth: ……………………………………………………………

Nationality: ...... …………………………… Religion: …………………………………………… Ethnicity: ......

Languages spoken at home: …………………………………………………………………………..

Child’s NHS number……………………………………………………………………………………………………………

Parents/carers name/s………….……………………………………………. …………………………………………………………………

Address/es …………………………………………………………………….. …………………………………………………………………

Postcode/s …………………………………………………………………….. …………………………………………………………………

Parents NI numbers…………………………………………………………… …………………………………………………………………

Home telephone no./nos……………………….……………………………… ..……………………………………………………………..

Mobile nos. ……………………………………………………………………… ……………………………………………………………….

Email ……………………………………………………………………………………… ………………………………………………………………

NI number……………………………………………………………………………. ……………………………………………………………….

Place/s of Employment……………………………………………………….. ………………………………………………………………..

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

Tel. no.……………………………………………………………………………………. …………………………………………………………………

Who has parental legal responsibility …………………………………………………………………………………………………………………...

Tel no………………………………………………………………………………………….Email………………………………………………………………………….

Names and ages of any other children in your family

Names / D.O.B.s

Emergency Contacts & people authorised to collect your child (not yourselves)

Name ……………………………………………………… Relationship …………………………………………………………

Address ……………………………………………………………………………………………………………………………………………………………

Tel. ……………………………………………………… Mobile no. …………………………………………………………

Name ……………………………………………………… Relationship …………………………………………………………

Address ……………………………………………………………………………………………………………………………………………………………

Tel. ……………………………………………………… Mobile no. …………………………………………………………

Name ……………………………………………………… Relationship …………………………………………………………

Address ……………………………………………………………………………………………………………………………………………………………

Tel. ……………………………………………………… Mobile no. ……………………………………………………

Medical details

Doctors Name …………………………………………………………… Tel. no. …………………………………………………………………………

Address ……………………………………………………………………………………………………………………………………………………………

Health visitors name……………………………………………………………………..Tel. no. ……………………………………………………………

Does your child need any special care? YES/NO

If yes please give details……………………………………………………………………………………………………………………

Is he/she on any long-term medication? YES/NO

If yes please give details……………………………………………………………………………………………………………………

Is he/she allergic/has food intolerance to anything? YES/NO

If yes please give details……………………………………………………………………………………………………………………

Does your child have any religious dietary requirements? YES/NO

If yes please give details……………………………………………………………………………………………………………………

Has he/she been in hospital recently? YES/NO

If yes please give details……………………………………………………………………………………………………………………

Will you allow us to give your child any emergency treatment that may be necessary? YES/NO

Has your child been immunised against? / Tetanus / Meningitis / Diphtheria / Polio / MMR / Whooping Cough /
Yes
No

Pre-school/nursery/school details

Are you claiming for the 30 hours funding YES/NO

If yes please note your voucher code……………………………………

Does your child attend any other establishment e.g. private/school nursery? YES/NO

If yes which one? ………………………………………………………………………………………. No. of hours/week…………………..

When will he/she start school? ……………………………… Which school? ……………………………………………

Miscellaneous details

May we take photographs and videos of your child for their profiles and for displays around the room YES/NO?

May photographs of your child be included on our website www.kidstimeleeds.co.uk ? YES/NO

Has he/she any special words for asking to be taken to the toilet? (preschool children only) YES/NO

If yes please give details……………………………………………………………………………………………………………………

I am aware of Kidstime’s policies & procedures YES/NO

Has he/she any special fears YES/NO If yes please give details……………………………………………………………………………………

Are there any recent events that may have affected your child i.e. moving house, new baby, bereavement, divorce etc? YES/NO

If yes please give details……………………………………………………………………………………………………………………

May we take you child for walks within the school grounds? YES/NO

Would you be prepared for your child to travel in a car if properly restrained? YES/NO

Can we apply our suncream/your own suncream to your child? (delete as applicable) YES/NO

If there is any other information, which is relevant to the care of you child, please give details on additional sheet.

UNIQUE PASSWORD:…………………………………………………………(please add a password of your choice)

I am aware that a four weeks’ notice period must be given for all changes or cancellations.

PARENT’S SIGNATURE ……………………………………………………………………………Date………………………………..

PARENT’S NAME PRINTED ……………………………………………………………………………

CHECKED …………………………………………………………………………..(Staff signature) Date…………………………………………..

REVIEWED (after one year) …………………………………………………………………………….Date……………………………….

PLEASE NOTIFY US IF ANY OF THE ABOVE INFORMATION CHANGES. THANK YOU.

Member of the Pre-school Learning Alliance & Leeds Play Network, Kidstime St Joseph’s Out of School Club Barleyfields Road Wetherby LS22 Tel. 07534622040