Registration Form for Little Heroes Nurseries

Child’s first name: *

Child’s surname: *

D.O.B: *

Age:

Preferred name:

Gender: *

Male

Female

Address:

Kings House
8 Station Road

Post code:

Primary contact first name: *

Surname: *

Relationship:

Address: *

Kings House
8 Station Road

Contact number: *

Work number:

Email address: *

Occupation:

Are there any other contact restrictions?:

Yes

Details:

Safia Parker

Secondary contact first name:

Surname:

Relationship:

Address:

8 Station Rd

Contact number:

Work number:

Email address:

Occupation:

Custody of the child is with:

Primary contact

Secondary contact

Both (joint custody)

Other

Emergency Contact no.1 name: *

Relationship:

Address:

84 Redway Drive
Whitton
Twickenham
Middx
TW2 7NW

Mobile number:

Work number:

Contact No.2 name:

Relationship:

Address:

84 Redway Drive
Whitton
Middx
TW2 7NW

Mobile number:

Work number:

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

Rosalind Laher, Christine Parker, Edmund Parker

Doctor's name:

Surgery address:

Thorkhill Practice, Thorkhill Gardens, Long Ditton

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:

Generally prefers baby lead weaning

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

Keppra twice daily (not at nursery) 1ml dose

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:

NA

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

N/A

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

Any other instructions : Please send a copy of your child’s birth certificate and immunisation records via Cheqdin’s registration messages section in your web portal login or email it to info@little-heroes-nurseries.com. For more details, please visit our website: www.little-heroes-nurseries.com.:

Declaration :

I accept the terms and conditions of Little Heroes Nurseries

Yes No

Full Name of Parent/Carer:

Digital Signature

Safia Parker

Date & time:

25, Apr 2021 06:06 pm

Little Heroes

Child Details

Parental Responsibility

Emergency Contacts

Medical Info

Other Details

Consents

Terms of Service