Registration Form for St Margarets Infant ASC

Child’s first name: *

Child’s surname: *

D.O.B: *

Gender: *

Male

Female

Child's school:

Class:

Address:

made up address

Post code:

Primary contact first name: *

Surname: *

Relationship:

Address: *

made up

Contact number: *

Work number:

Email address: *

Are there any other contact restrictions?:

Yes

Details:

Test booking only

Secondary contact first name:

Surname:

Relationship:

Address:

24 Pembury Way,
Rainham
Gillingham 
Kent

Contact number:

Work number:

Email address:

Contact no.1 name:

Relationship:

Address:

made up

Mobile number:

Work number:

Contact No.2 name:

Relationship:

Address:

33 Arthur road

Mobile number:

Work number:

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

correct

Doctor's name:

Surgery address:

made up

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:

Dislikes: being asked to do something

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

Blue inhaler - school office

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:

MLD, suspected ASC/PDA - awaiting assessment

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

C is a LAC that has suffered trauma in the past. She has ADHD .

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

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

Declaration :

I accept the terms and conditions of [Centre Name]

Yes No

Full Name of Parent/Carer:

Digital Signature

katy

Date & time:

07, Jun 2021 01:12 pm

St Margarets Infant ASC

Child Details

Parental Responsibility

Emergency Contacts

Medical Info

Other Details

Consents

Terms of Service