Heyhouses Endowed Church of England Primary School

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20th December 14
Trail : home / Nursery : Application Form

Application Form

ENROLMENT FORM

HEYHOUSES CHURCH OF ENGLAND NURSERY SCHOOL

 

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

 

 

 

 

 

 EMERGENCY CONTACTS

 

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)

 

MEDICAL EMERGENCY

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)

PERMISSION FOR SUPERVISED WALKS

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)

PHOTOGRAPHS/VIDEOS

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 __________________