Naylor Road, Widnes, WA8 0BS.
Headteacher – Amanda Brown Tele : 0151 424 4686
Fax : 0151 495 9290
Pupil Application FormEmail :
Child’s DetailsSurname / Legal Surname / First Name / Date of birth / Male/Female
Child’s AddressPostcode / Number/Name / Street / Town
Contact DetailsHome / Mobile
Family/Carer/Emergency Contact (Mother, Father, Grandparent, Auntie, Uncle)Contacts / Relationship / Surname / First Name / Home Contact / Mobile Contact
From the above please circle who has parental responsibility1st / 2nd / 3rd / 4th / 5th
MedicalName / Address / Contact Number
Does your child have any Medical Conditions / Allergies that the school should be aware of?
In the case of a medical emergency where the parent/carer cannot be contacted. I give permission for my child to receive emergency medical treatment. (Please Circle)YES / NO
Signature / Print Name / Relationship / Date
EthnicityChilds Ethnic Origin / Language / Religion
Birth DetailsBirth Certificate Number / Country of Birth / Nationality
Early Years Pupil Premium
Early Years Providers are able to claim additional funding for your child. This funding depends on the parental income and other orders. If your income is less than £16,190.00 or your child is Adopted from Care, subject to a Special Residence Order or Child Arrangements Order your child may qualify for the nursery school to claim to provide an extra £300.00.Income less than £16,900.00 / YES / NO
Adopted from Care / YES / NO
Special Residence Order / YES / NO
Child Arrangements Order / YES / NO
Parent/Carer Surname / Parent / Carer National Insurance Number / Parent / Carer Date of Birth / Parent Carer National Asylum Support Reference Number (if applicable)
The information I have given on this form is complete and accurate. I understand that my personal information is held securely and will only be used for Local Authority purpose. I agree to the Local Authority using this information to enable my child’s nursery to claim the Early Years Pupil Premium for my child.Parent / Carer Signature / Date
During your child’s time at Warrington Road Nursery School he/she may have photographs taken and a DVD recorded. At the end of the school year a DVD is made of all the children, showing many events held in nursery and is available to purchase.
From time to time activities that the children take part in may go into the local newspaper and be displayed on our website giving their name and a photograph.
Children’s records are passed to their new school/setting on transition.
If you agree to the above please sign the disclaimer below. If you have any concerns regarding this please do not hesitate to contact us.Signature / Print Name / Relationship / Date
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