Registration Form for Rendell Primary School

Child’s first name: *

Child’s surname: *

D.O.B: *

Age: *

Preferred name:

Gender: *

Male

Female

Child’s First language: *

Child’s Second Language:

Address: *

Frederick Ave

Post code:

Primary contact first name: *

Surname: *

Relationship:

Address: *

Frederick Ave

Contact number: *

Work number:

Email address: *

Occupation:

Are there any other contact restrictions?:

Yes

Details:

Rikin Kotecha

Secondary contact first name:

Surname:

Relationship:

Address:

14 Fennel Street, flat 8

Contact number:

Work number:

Email address:

Occupation:

Custody of the child is with:

Primary contact

Secondary contact

Both (joint custody)

Other

Contact no.1 name: *

Relationship:

Address:

105 station Street
LE11 5EG

Mobile number:

Work number:

Contact No.2 name:

Relationship:

Address:

25 Lowther Way,Loughborough,LE112LF

Mobile number:

Work number:

I, hereby consent and grant permission to the following persons to collect my child (Must be 18 years or over):

My dad( Ashik Uddin) or my sister (Fahima begum,) (Amina begum), or( Mohammed Burhan Uddin) can pick Al-Yasa up if were both unavailable. They all live at ( 16 Hartington street)

Doctor's name: *

Surgery address:

28 Bridge Street
LE11 1NH

Surgery phone Number:

Allergic reactions - Severity: *

Very high

High

Medium

Low

Allergies, if any: *

Medical conditions, if any:

Does your child have any dietary requirements?:

Yes

Special needs:

Specific likes/dislikes:

She gets scared so easily with loud noises or  aggressive/unexpected behaviours.
She needs her calm person to hugh her and make her feel secure and protected, so see can carry on with the day/activity as always.

Medication (Please list any medication your child takes regularly and the dosage):

None

Does your child have any special educational needs (SEN)?:

Yes

If your child has any learning difficulties/disabilities or requires additional assistance, please list them here: *

None

Any other relevant information we may need to be aware of ?:

None

Please read our Terms & Conditions View T&C's

Any other instructions : Please send a copy of your child’s birth certificate, immunization records via Cheqdin’s registration messages section in your parent’s web portal login or email it to. This form must be signed by the parent(s)/guardian(s) applying for admission of the named child and who it is assumed will be responsible for the fees. For more details, please visit our website: www.insert-your-website-address-here.com.:

Declaration :

I accept the terms and conditions of [Centre Name]

Yes No

Full Name of Parent/Carer:

Digital Signature

Rikin Kotecha

Date & time:

10, May 2022 10:42 am

Little Owls Preschool

Child Details

Parental Responsibility

Emergency Contacts

Medical Info

Other Details

Consents

Terms of Service