Registration Form for Finnegan Fox Afterschool

Child’s first name: *

Child’s surname: *

D.O.B: *

Age: *

Preferred name:

Gender: *

Male

Female

Child's school:

Class:

Teacher:

Address:

718 Howth Road, Raheny

Eircode:

Days Attending: *

Primary contact first name: *

Surname: *

Relationship:

Address: *

718 Howth Road, Raheny, Dublin 5

Contact number: *

Work number:

Email address: *

Occupation:

Are there any other contact restrictions?:

Yes

Details:

Siobhan Hyland

Secondary contact first name:

Surname:

Relationship:

Address:

718 Howth Road, Raheny, Dublin

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:

18 Mount Prospect Avenue, Clontarf, Dublin 3

Mobile number:

Contact No.2 name:

Relationship:

Address:

45A conquer hill road, Clontarf

Mobile number:

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

Both emergency contacts can collect - Alison Mahon & Kate Hogan

Doctor's name:

Surgery address:

Collins Ave, Killester, Dublin 5

Surgery phone Number:

Allergens severity: *

Very high

High

Medium

Low

Allergen's Name:

Medical condition(s) if any:

Does your child have any dietary requirements?:

Yes

Special needs:

Specific likes/dislikes:

Cars, playing pretend play (chef, docter etc), playing with friends

Medication:

Only if necessary, blue inhaler (2 puffs)

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

Yes

If your child requires additional assistance with anything, please let us know here:

May need to be reminded to go to the toilet

Religion:

Christian

Muslim

Buddhist

Jewish

Sikh

Hindu

None

Prefer not to say

Others - please state

Secret password:

Other Religion:

First language:

English

Any other relevant information:

Second language is Portuguese

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

Any other instructions : Please ensure to complete a separate form for younger siblings on the waiting list!:

Declaration :

I accept the terms and conditions of [Centre Name]

Yes No

Full Name of Parent/Carer:

Digital Signature

Janet Mahon

Date & time:

04, Jan 2021 02:45 pm

Finnegan Fox Afterschool

Child Details

Parental Responsibility

Emergency Contacts

Medical Info

Other Details

Consents

Terms of Service