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CHILD REGISTRATION FORM EDITED MAY 17

YOUR CHILDFull Name:Address:

Date of Birth:Gender: Girl / Boy

Proposed Start Date:Actual Start Date:Religion:Main language spoken at home:Second language spoken at home:Ethnicity (please tick one)White British White IrishTraveller of Irish Heritage Gypsy / RomaWhite any other background Mixed, White and Black CaribbeanMixed White and Black African Mixed, any other mixed backgroundAsian or Asian British, Indian Asian or Asian British PakistaniAsian or Asian British Bangladeshi Asian or Asian British, any other Asian

backgroundBlack or Black British, Caribbean Black or Black British, AfricanBlack or Black British, any other background ChineseAny other background Prefer not to say

CONTACT DETAILS PARENTS / GUARDIANS (PLEASE DELETE AS APPROPRIATE)First Carer’s Details:Title and full name:Relationship to child:Does this person have parental responsibility for the child? YES / NODoes this person have legal contact with the child? YES / NOIf no, please give detailsIs this person the bill payer? YES / NOHome address if different:

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Postcode:Home phone number:Mobile 1:Mobile 2:Work contact number:Employer name:Email address:

Second Carer’s Details:Title and full name:Relationship to child:Does this person have parental responsibility for the child? YES / NODoes this person have legal contact with the child? YES / NOIf no, please give detailsIs this person the bill payer? YES / NOHome address if different:

Postcode:Home phone number:Mobile 1:Mobile 2:Work contact number:Employer name:Email address:

If the persons named above DO NOT have parental responsibility for the child or legal contact, please tell us who does:

Is there anyone else, not mentioned above, who has parental responsibility or contact?

EMERGENCY CONTACT DETAILSIn the event of an emergency please nominate a person we may contact and will be able to collect your child if they are unable to remain at the setting due to illness or other emergency. Contacts should be local to the setting if possible.

First Emergency Contact:Title and full name:Relationship to child:Home address:

Postcode:Home phone number:

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Mobile 1:Mobile 2:Work contact number:Employer name:

Second Emergency Contact:Title and full name:Relationship to child:Home address:

Postcode:Home phone number:Mobile 1:Mobile 2:Work contact number:Employer name:

HEALTHDoctor Name and Address Phone:

Name of Health VisitorAre your child’s immunisations up to date? YES / NOIf no please provide details:

Does your child have asthma? YES / NOIf yes please provide details:

Does your child have allergies? YES / NOIf yes please provide details:

Does your child have any other medical conditions? YES / NOIf yes please provide details:

Does your child take medication? YES / NOIf yes, please provide details:

Will they require it while at the setting? YES / NOIf yes, you may be asked to complete further medical forms or a medical alert form.If your child has a serious accident or becomes ill while in the care of Iver Community Childcare, we will always contact you to let you know. It is important however that treatment is given without delay and we ask that you authorise us in advance to seek the most appropriate treatment by a member of staff trained in first aid, a doctor or

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other medical professional.I give permission for Iver Community Childcare to seek emergency medical treatment and advice for my child.Carer 1:Carer 2:Has your child ever been referred to any of these specialists?Speech Therapist AudiologistOrthopist Community PediatricianOccupational Therapist PhysiotherapistPsychologist DieticianOther Health VisitorIf yes, please provide details:

I give permission for Iver Community Childcare to share information with the above specialistsYES / NOParent / Carer Signature:Date:Do you have any concerns regarding your child’s development? YES / NOIf yes, please provide details:

Does your child have an Educational Healthcare Plan? YES / NOIf yes, please provide a copy.Is parent / carer a member of the armed forces? YES / NOIs your child subject to a child in need plan or a child protection order? YES/NOIf yes, please provide name and contact details for the social workers involved.

Is your child registered at The Iver’s Children Centre YES / NOIf yes, are you happy for us to share information regarding your child’s education and development with Centre staff? YES / NOIf no, would you like to register? YES / NO

DIETARY NEEDSIs your child a vegetarian? YES / NODoes your child have any special religious or dietary needs? YES / NOIf yes, please provide details:

Can your child have milk? YES / NO

PERMISSIONSI give permission for Iver Community Childcare to apply factor 30+ hypoallergenic sunscreen on sunny days.

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YES / NO / only what I supplyParent / Carer signature:Date:I give permission for my child to have his / her face paintedYES / NOParent / Carer signature:Date:Calpol Permission:If your child develops a high temperature while at the setting, you may like us to give them Calpol, or a similar medication, which we are unable to do, unless we have your written permission. If this ever becomes necessary, we will always phone and seek verbal permission before giving the medication and you would be asked to sign a Verbal Medication Confirmation Form when you collect your child.

To ensure that a child does not receive too much medication, no child will be given Calpol or similar medication within their first three hours at the setting, unless a long term medication daily update form has been completed, which confirms when the child received their last dose of the medication.I give permission for Iver Community Childcare to give my child Calpol or similar medication, for the treatment of a high temperature. I understand that I will need to complete a long term medication daily update form if my child has received Calpol or similar medication, before arrival at the setting.Parent / Carer signature:Date:I give permission for my child to be taken on short trips out of the setting in the local area. Eg-local park, libraryYES / NOParent / Carer signature:Date:I give permission for my child to have their photograph taken during activities and used for display as follows (please tick those that apply)In their work In other children’s workOn noticeboards around the setting In advertising materialFor their records For our records to demonstrate compliance to

regulatory authoritiesParent / Carer signature:Date:I give permission for staff to observe and keep written records about my child. These will be stored securely in the child’s records or learning journalParent / Carer signature:Date:I give permission for my child’s learning journal, or a summary of this (containing observations and photographs), to be passed on to the next school or nursery that my child will attend when they leave this setting.Parent / Carer signature:Date:I give permission for childcare students to observe my child and keep written records which can be used to form part of the student’s essays and assignments. As these observations will be made available to assessors and tutors from outside the setting the child will not be named of otherwise identified.Parent / Carer signature:Date:

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The password I would like to be use when collecting my child is:I am happy to receive invoices by email? YES/NO

I/we confirm that the information provided in this form is accurate and that I/we have disclosed all medical information known to us and will advise Iver Community Childcare of any changes to my/our child’s medical condition and accept full responsibility should we fail to do so.Carer 1: Date:Carer 2: Date:

FOR OFFIC USE ONLYMedical Information reviewed by Section Manager YES / NOMedical form needs to be completed YES / NOCompleted Date:Medicine form needs to be completed YES / NOCompleted Date:Medical Alert meeting required YES / NOMeeting Held Date:SENCO Meeting required YES / NOMeeting Held Date:Red Book seen YES / NO

Signed Terms and Conditions Received YES / NOAll About Me Received YES / NOSession Information Received YES / NOFFE Form Completed YES / NOPupil Premium Form Completed YES / NOChildren’s Centre Registration Form Completed YES / NOProof of date of birth seen PASSPORT/BIRTH CERTIFICATE/OTHER YES / NOSigned: Date: