Registration Form for The Shepherd's Hut

Student first name: *

Student surname: *

D.O.B: *

Preferred name:

Student's gender: *

Male

Female

Prefer to self-describe

Start date: *

Address: *

Magnolia Cottage
28 Church Street
Great Missenden

Post code: *

Does your child currently attend another setting or has done previously?: e.g nursery/childminder/preschool *

yes

Sessions required: *

Primary contact first name: *

Surname: *

Relationship: *

Address: *

Pera Casa, Nags Head Road, Great Missenden

Contact number: *

Work number:

Email address: *

Occupation:

Are there any other contact restrictions?:

Yes

Details:

Available to be contacted all day. Own my own businesses.

Secondary contact first name: *

Surname: *

Relationship: *

Address: *

Pera Casa, Nags Head Road, Great Missenden, HP16 0EP

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: *

18 honorwood close, Prestwood HP16 9HJ

Mobile number: *

Work number:

Contact No.2 name:

Relationship:

Address:

18 honorwood close Prestwood HP16 9hj

Mobile number:

Work number:

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

Gina and Erich Herrmann

Allergic reactions - Severity: *

Not Applicable

Very high

High

Medium

Low

Allergies, if any:

Medical conditions, if any:

Does your child have any dietary requirements?:

Yes

Special needs:

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:

N/A

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

No

Doctors name: *

Rectory meadow

Surgery address: *

Rectory meadow Rectory Meadow Surgery
School Lane
Old Amersham
Buckinghamshire
HP7 0HG

Surgery phone number: *

01494 727711

Specific likes/dislikes: *

None - will complete closer to start date

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

N/A

Any other relevant information we may need to be aware of? N/A if not applicable: *

NA

Religion:

Christian

Muslim

Buddhist

Jewish

Sikh

Hindu

None

Prefer not to say

Others - please state

Other Religion:

Secret password: *

Bella

First Language:

English

Any other relevant information:

No

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 regisitration messages section in your web portal login or email it to ebaker@theshephut.co.uk

Declaration :

I accept the terms and conditions of The Shepherds Hut Outdoor Day Nursery LTD

Yes No

Full Name of Parent/Carer:

Digital Signature

Tami

Date & time:

29, Jul 2024 10:00 am

The Shepherd's Hut - Great Missenden

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