Registration Form for Basecamp Childcare

Student first name: *

Student surname: *

D.O.B: *

Age:

Preferred name:

Student's gender: *

Male

Female

Prefer to self-describe

Describe Gender:

Is your child currently attending a school or nursery?:

Yes

Child’s Current School:

Class Name:

Year:

Address:

123 Donald Duck Road

Post code:

Language(s) spoken:

Is English your child's first language?:

Primary contact first name: *

Surname: *

Relationship:

Address: *

123 Donald Duck Road

Contact number: *

Work number:

Email address: *

Occupation:

Are there any other contact restrictions?:

Yes

Details:

Heather Cordiner

Secondary contact first name:

Surname:

Relationship:

Address:

12 Silk Close, London SE12 8DL

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:

123 Donald Duck Road

Mobile number:

Work number:

Contact No.2 name:

Relationship:

Address:

206 Carlton Avenue, Westcliff-on-Sea, Essex SS0 0QD

Mobile number:

Work number:

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

Fatmata Sillah

Allergic reactions - Severity: *

Not Applicable

Very high

High

Medium

Low

Allergies, if any:

Medical conditions, if any:

Does your child have any dietary requirements?:

Yes

Special needs:

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:

Autism and ADHD.

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

She is asthmatic.

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

Any other instructions :

Early registration is recommended. Registrations will be considered in the order in which they are received. This form must be signed by the parent(s)/ guardian(s) with parental responsibility; 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: https://basecampchildcare.co.uk/.

Declaration :

I accept the terms and conditions of Basecamp Childcare.

Yes No

Full Name of Parent/Carer:

Digital Signature

Stacey Ellis

Date & time:

06, Nov 2024 11:37 am

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