Heyhouses Endowed Church of England Primary School

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25th October 16
Trail : home / Nursery : Application Form

Application Form




1        Your Child


      Surname __________________________      Male [ ] Female [ ]


      Forename(s) _______________________ Date of birth ____________________


      Child's Home Address _______________________________________________


      Post Code ___________ Telephone __________________ E-mail ____________


2        Parent(s)/Legal Guardian(s) (persons who are responsible for the child)


      Mother's Name ___________________ Father's Name _____________________


      Address _________________________ Address __________________________




      Telephone _______________________ Telephone ________________________

      If different from Child's                     If Different from Child's


3        Please tick the sessions preferred (minimum 3 sessions)


AM                       Monday         [ ]                PM               Monday         [ ]

Only                    Tuesday        [ ]                Only            Tuesday        [ ]

                             Wednesday    [ ]                                   Wednesday    [ ]

                             Thursday       [ ]                                   Thursday       [ ]

                             Friday           [ ]                                   Friday           [ ]

FULL DAY         Monday         [ ]                Preferred start date

With lunch      Tuesday        [ ]

                             Wednesday   [ ]                Month ______________

                             Thursday      [ ]

                             Friday           [ ]                Year _______________


Please note - every effort will be made to reserve your preferred sessions.  In the event of those sessions being unavailable alternative sessions will be offered wherever possible.


4        Does your child require milk at Snack Time:  Yes [ ]  No [ ] Allergy/Dislikes

5        Does your child require a school meal:   Yes [ ]    No [ ]

6        Breakfast Club: Yes [ ]  No [ ] Days: ..............................................................

7        Extended Lunchtime until 1 pm or from 12pm : Yes [ ]  No [ ] Days: .....................

8        After Nursery Yes [ ]  No [ ] Days: .................................................................

9        Deposit attached  - 25.00 [ ] cheques payable to 'Heyhouses C of E Nursery School Ltd'


I/we confirm that the information on this form is accurate and understand that completion of this form does not guarantee admission to Nursery.


Signature of Parent/Guardian __________________________ Date ____________



Please could you give details of any difficulties or needs your child has or has had in the past, in order that we can offer the best support when they start nursery.  All information will be treated with confidence.



Where the answer to any of the questions below is Yes, please provide details.


1.  Has your child received treatment or therapy for difficulties with hearing vision or speech?                                                   Yes [ ] No [ ]




2.  Does your child suffer from allergies, asthma, epilepsy, physical difficulties or any other medical problem?  Please give details.              Yes [ ] No [ ]




3.  Has your child had support from Blenheim House?                      Yes [ ] No [ ]




4.  Are there any home or family circumstances or other information the Nursery staff should be aware of?                           Yes [ ] No [ ]




5.  May information be sought from the required persons eg health visitors. GP as appropriate?                                                Yes [ ] No [ ]





6.  Any additional comments you would like to make.





Signature of Parent/Guardian _______________________ Date ________



When you visit Nursery you will have the opportunity to read our Policies & Procedures, the main ones are included in the Parents Handbook.  Would you please sign below to say that you accept them.  If you would like further information please speak to a member of staff.


Signature of Parent/Guardian _______________________ Date ________


Please inform Nursery of any change in your circumstances








Please complete the following details and sign each section below


CHILD'S NAME ____________________________________



Name of first contact _____________________________________________________


Relationship to child/family ________________________________________________


Home telephone/address _________________________________________________


Work telephone/address __________________________________________________


Name second contact ____________________________________________________


Relationship to child/family ________________________________________________


Home telephone/address _________________________________________________


Work telephone/address _________________________________________________


Name third contact ______________________________________________________


Relationship to child/family ________________________________________________


Home telephone/address _________________________________________________




Work telephone/address __________________________________________________


I give permission for all of the above Emergency Contacts to sign for my child in the event of an emergency

SIGNED ___________________­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­__________________________________ (Parent/Guardian)



Please give the name address and telephone number of the family GP:


Name Dr_________________ Address __________________________________Tel ___________

This is to give permission to the Staff of Heyhouses Nursery to take whatever action is deemed necessary in a medical emergency.


PERMISSION TO APPLY PLASTERS:  YES         NO       (please select) SIGNED_______________


SIGNED ________________________________________ (Parent/Guardian)


I do/do not (please delete as appropriate) agree to my child being taken for supervised walks from Heyhouses Nursery, e.g., to the church, infant department, etc.


SIGNED ________________________________________ (Parent/Guardian)


I do/do not (please delete as appropriate) agree for my child to have their photograph taken and displayed in Nursery or sent to the newspaper. I do/do not agree for my child to be videoed during sports day, nativity or other such events.

SIGNED _________________________________________ (Parent/Guardian)


PASSWORD: ­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­___________________________________ DATE __________________