Registration Form for Pitter Patter Play Ltd

Child’s first name: *

Child’s surname: *

D.O.B: *

Age:

Preferred name:

Gender: *

Male

Female

Child's school:

Class:

Year:

Address:

33 Seabreeze Drive, Newport

Post code:

Primary contact first name: *

Surname: *

Relationship:

Address: *

30 roe deer drive

Contact number: *

Work number:

Email address: *

Occupation:

Are there any other contact restrictions?:

Yes

Details:

Secondary contact first name:

Surname:

Relationship:

Address:

30 roe deer driver Ipswich capel st Mary ip9 2ln

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:

30 Roe Deer Drive, Capel St Mary, Ipswich, Ip9 2ln

Mobile number:

Work number:

Contact No.2 name:

Relationship:

Address:

43 Falcon Street, Felixstowe, Ip11 9dr

Mobile number:

Work number:

Doctors name, phone number and address: *

Constable county medical practice, Capel St Mary

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:

Emilia enjoys buttered crackers, buttered bread/toast, croissants, cheerios, wafer, crisps, sausage rolls, jelly.

Emilia enjoys plain food such as rice, chips, pasta, fish, pork, chicken, peas, sweetcorn.
She does not like potato, pizza, tomato sauce.

She enjoys fruits such as grapes, apples, banana

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:

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

Emilia is prone to accidents when she's away from home so she does tend to wear disposable pants for easy changing. 

She also has dark patches on her back/ bottom known as Mongolian Blue Spots. These have been noted in her medical records since birth.

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:

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

Ashton Horne

Date & time:

09, Dec 2023 07:50 pm

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