Child’s first name: *

Child’s surname: *

D.O.B: *

Age:

Preferred name:

Gender: *

Male

Female

Child's school:

Class:

Year:

Address:

Jenkins terrace Maesteg

Post code:

Birth certificate no:

Primary contact first name: *

Surname: *

Relationship:

Address: *

30 upper street
Maesteg 
CF34 9DU

Contact number: *

Work number:

Email address: *

Occupation:

Are there any other contact restrictions?:

Yes

Details:

Alex Allegretto

Secondary contact first name:

Surname:

Relationship:

Address:

110 meadow Rise

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:

48 parc tyn y wayn
Llangynwydd

Mobile number:

Work number:

Contact No.2 name:

Relationship:

Address:

101 pentyla road
Baglan

Mobile number:

Work number:

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

James harris 
Lindsay harris
Use password - Swansea

Doctor's name:

Surgery address:

Woodlands surgery
Caerau

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:

Ava is a fussy eater,
Loves grapes apple banana  sweet corn nuggets

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

Trimethripin daily for kidney

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:

Waiting for autism assessment

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

Amber was born with Laryngomalacia, basically means she was born with a floppy Larynx. Its a condition that will eventually go as she gets older, its almost gone now. It doesnt affect her in anyway at all apart from causes her breathing to sound very noisy! It can sound quite alarming if youre not used to it although it is absolutely nothing to worry about and doesnt bother her at all. She does allot of grunting sounds and sometimes her laugh is raspy, just thought we'd make you aware incase it causes concern.

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:

Can be sensitive and shy. May get upset at first but should be ok after seeing his sister Ferne and playing

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 web portal login or email it to centre’s email ID. 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

Nadia jeremy

Date & time:

24, Mar 2020 10:04 am

Little Stars Daycare

Child Details

Parental Responsibility

Emergency Contacts

Medical Info

Other Details

Consents

Terms of Service