Early Birds & Night Owls
/ Reg. Charity no 1070970
0FSTED Inspected / C/o Wrenthorpe Junior & Infant School
Imperial Avenue
Wrenthorpe
WAKEFIELD
WF2 0LW
Tel: 01924 370770
(Mon to Fri 7.30am – 6.00pm))

EARLY BIRDS AND NIGHT OWLS APPLICATION FORM

All information on this form is confidential and will only be released to appropriate staff

or committee members

Full name of child: / (Please underline usual first name used)
Date of Birth: / Age:
Child’s Home Address: / POST CODE:
Home Tel No:
Mother’s Name: / Work Tel No:
Mobile Tel No:
Father’s Name: / Work Tel No:
Mobile Tel No:

In an emergency, who else could be contacted e.g: relative, childminder, neighbour:-

Name: / Tel No:
Name: / Tel No:
Which school does your child attend?
Is there anyone who should not collect your child? If so, please name.
EARLY BIRDS BREAKFAST CLUB

DAY

/ Please tick as required / 7.30 OR 8.00 AM / Breakfast
(please tick if breakfast is required)

Monday

Tuesday
Wednesday
Thursday
Friday

NIGHT OWLS AFTER SCHOOL CLUB

DAY

/ Please tick as required / 3.20 – 4.20PM / 3.20 – 5.20PM / 3.20 – 6.00PM

Monday

Tuesday
Wednesday
Thursday
Friday
Doctors name and Tel No:
I GIVE/DO NOT GIVE permission for Playworkers to seek medical treatment for my child in an emergency (please delete as appropriate)
Has your child been immunised against the following (tick as appropriate):
Diptheria: / Whooping Cough: / Polio:
Tetanus: / MMR: / Hib:
Has your child any allergies e.g: to food, animals or any other medical condition, or health problem which should be noted in case of emergency, or which could affect their activities at Early Birds/Night Owls? If yes, please give details:
Does your child have any dislikes? If yes, please give details.
Is your child on any medication? If yes, please give details.
Have you or your child any special needs? Please give details so we can discuss at an early stage any extra help you may require:
Does your child receive any form of extra help already e.g. speech therapy, physiotherapy?
Does your child have any particular interests, hobbies or activities?
Occasionally the children are taken out for walks to the park, shops, outings etc and into the garden area for outdoor play activities. Playworkers and parents supervise these outings. Do you agree to your child taking part in such activities? YES/NO (Delete as appropriate)
A parent management committee runs Early Birds and Night Owls. We require up to 12 people each year for the committee. Would you be interested in joining the committee?
YES/NO (Delete as appropriate)
I confirm that the information given above is correct to the best of my knowledge
SIGNED: / DATE:
To ensure we welcome and reaches all families in the local community please would you answer the following voluntary questions? Is your family (tick as appropriate):-
Afro-Caribbean: / African: / Asian:
British: / Other European: / Other:
(Please write in)
Mother’s occupation: / Father’s occupation:

EBAppForm/REV 1/Jan 2007