Registration Form for Mini Buddies Nursery and Out of hours Care

Child’s first name: *

D.O.B: *

Child’s surname: *

Age:

Preferred name:

Gender: *

Male

Female

Child's school:

Class:

Year:

Address:

31 Palatine Road

Post code:

Primary contact first name: *

Surname: *

Relationship:

Address: *

31 Palatine Road

Contact number: *

Work number:

Email address: *

Occupation:

Are there any other contact restrictions?:

Yes

Details:

Mrs Emma Greenwood

Secondary contact first name:

Surname:

Relationship:

Address:

31 Palatine Road

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:

5 slinger road

Mobile number:

Work number:

Contact No.2 name:

Relationship:

Address:

5 slinger road

Mobile number:

Work 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:

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:

Autism Adhd, hearing loss

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

No

Religion:

Christian

Muslim

Buddhist

Jewish

Sikh

Hindu

None

Prefer not to say

Others - please state

Other Religion:

Secret password:

First language:

English

Any other relevant information:

None

When would you like your child to start with us?:

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

Any other instructions : 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 [Club Name]

Yes No

Full Name of Parent/Carer:

Digital Signature

Abbie

Date & time:

27, Aug 2023 09:11 pm

Mini Buddies Nursery and Out of Hours Care

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