Admissions form

Type of place booked: *

Breakfast/After school club site/location: *

Holiday club site/location: *

Nursery site/location: *

School attending: *

Class: *

Name of child: *

Name they like to be known by: *

Gender: *

Date of birth: *

Siblings attending the club: *

Class:

Funded place:

Attendance: *

Name of the parent or carer who has parental responsibility: *

Relationship to the child: *

Child's permanent place of residency: *

Home phone number: *

Work phone number:

Mobile phone number:

Which phone number can we contact you on when your child is with us? *

Email Address *

Please give the details of the person who will be dropping off and picking up the child on a regular basis: *

We will require written notification and a password if the child is going to be picked up by anyone other than the person/s named here; we will not release the child unless we are notified of any change.

Relationship to the child: *

Emergency contact details (if different to above):

GP name, address and phone number: *

Do you receive any support from other agencies/professionals? *

Please provide us with details including contact name, telephone number and details of support so that we can work in partnership to support your child whilst in our care.

Are you happy for us to contact your child’s previous/current childcare provider? *

Childcare provider and contact details:

Do you agree to Crazy 4 Kids where appropriate, liaising with internal and external agencies / professionals, i.e. Child’s School/Teacher in order to ensure continuity of care? *

Will you be applying for help with your childcare fees via the Working Tax Credit Scheme (Childcare)? *

Ethnic origin: *

We seek to ensure that all sections of the community have access to the positions that we have available within our company. This information will be used for monitoring and statistical purposes only. Any information provided will not be taken into account in evaluating applicants for consideration of employment or promotion with ourselves.

Other:

Home language: *

Religious or cultural needs: *

Other:

Any physical needs? *

Physical needs:

Dietary requirements: *

Other:

Allergies: *

Other:

Has your child got any medical conditions? *

Please describe the medical condition: *

Is your child taking prescribed medication: *

Prescribed medication taken: *

Will this be taken whilst they are attending the club? *

Medication frequency and dosage: *

We can only administer prescribed medication. Any medication brought into the club, must be handed to the Manager in its’ original bottle clearly marked with the full name of the child, the dosage and the frequency.

Will this condition affect their ability to participate fully in club activities? *

How will the condition affect their ability to participate fully in club activities? *

What adjustments do you feel the club can make in order to facilitate your child’s full participation within the club?

Please list sessions/times required: *

Please confirm full details of the agreed days, times and start dates.

By selecting the submit button below you confirm acceptance of our terms and conditions.

This form collects your details in line with our privacy policy and only for the purpose of managing your booking.