Holiday Club Registration Form Child's Details Forename(s) (required) Surname (required) Date of Birth (required) Gender (required) —Please choose an option—MaleFemale Address Line 1 (required) Address Line 2 (required) Address Line 3 Postcode (required) Which Parent or Carer does the child normally live with (required) Nationality Religion Language spoken at home Ethnicity —Please choose an option—White BritishIrishTraveller of Irish HeritageGypsy/RomaMixed White & Black CaribbeanWhite & Black AfricanWhite & AsianChineseBlack or Black BritishAsian or Asian BritishIndianPakistaniBangladeshiCaribbeanAfricanAny other White backgroundAny other Asian backgroundAny other Black backgroundAny other mixed background Special Educational Needs Does your child have any Special Educational Needs (required) —Please choose an option—YesNo If yes, please provide details below: If yes, does your child have a Statement of Educational Needs maintained by the LEA YesNo Dietary Requirements Can your child eat anything? (required) —Please choose an option—YesNo Please provide details: Is your child vegetarian? (required) —Please choose an option—YesNo Does your child have a food allergy or intolerance? (required) —Please choose an option—YesNo Please provide details: Medical Details Does your child have any medical conditions? (required) —Please choose an option—YesNo Please provide details: Does your child take regular medication? (required) —Please choose an option—YesNo Please provide details: Does your child have any allergies (required) —Please choose an option—YesNo Please provide details: Are there any medical procedures that are prohibited by family religion or beliefs? (required) —Please choose an option—YesNo If yes, please state: Healthcare Details Doctors Name (required) Telephone Address Line 1 (required) Address Line 2 (required) Address Line 3 Postcode (required) Father/Carer Details Title —Please choose an option—MrMrsMissMs Forename(s) (required) Surname If address if different from child’s home address please complete the address section below Home Address Line 1 Home Address Line 2 Home Address Line 3 Postcode Home Telephone Mobile Telephone Company Name Company Address Line 1 Company Address Line 2 Company Address Line 3 Postcode Work Telephone Email Mother/Carer Details Title —Please choose an option—MrMrsMissMs Forename(s) Surname If address if different from child’s home address please complete the address section below Home Address Line 1 Home Address Line 2 Home Address Line 3 Postcode Home Telephone Mobile Telephone Company Name Company Address Line 1 Company Address Line 2 Company Address Line 3 Postcode Work Telephone Email Emergency Contacts Please supply names and address of contacts, who could attend at short notice, in an emergency if we are unable to contact you or child’s Parent/Carer. 1st Contact Name Relationship to child Home Address Line 1 Home Address Line 2 Home Address Line 3 Postcode Telephone Mobile Can this person collect your child in an Emergency situation? —Please choose an option—YesNo 2nd Contact Name Relationship to child Home Address Line 1 Home Address Line 2 Home Address Line 3 Postcode Telephone Mobile Can this person collect your child in an Emergency situation? —Please choose an option—YesNo Persons Authorised to Collect your child Please give names of persons authorised to collect your child INCLUDING Parent/Carers. Please supply a photograph of all persons authorised to collect. Name Relationship to child Name Relationship to child Name Relationship to child Name Relationship to child To ensure your child’s safety and to avoid delays when collecting, please agree a password to be used on arrival by any of the individuals named above or to be provided in an emergency. The agreed password is: (required) Consent Offsite Activities I agree that Staff can take my child on walks in the local community for Off Site Activities. Staff will inform me, in writing, and request specific consent for activities that involve the use of Public and or any other forms of transport (required) —Please choose an option—YesNo Photographs within childcare setting I agree to photographs of my child to be used on displays, to support activities and provide evidence for Ofsted. These photographs can also be used for the children to refer to (required) —Please choose an option—YesNo Photographs for Promotional Literature I agree to the use of photographs of my child to put on promotional literature, displays for Open Evenings and for supporting student/work experience placement portfolios (required) —Please choose an option—YesNo Photographs for use on the Nursery Website I agree to the use of photographs of my child appearing on the Nursery website (required) —Please choose an option—YesNo Face Painting I agree for my child’s face to be painted (required) —Please choose an option—YesNo Hypoallergenic Plasters I agree for hypoallergenic plasters to be administered to my child (required) —Please choose an option—YesNo Pain and Fever Relief I agree that my child can be given Calpol for pain and Fever Relief (required) —Please choose an option—YesNo Allergic Reaction Relief I agree to Piriton Syrup being administered to my child in the event of an allergic reaction. (required) —Please choose an option—YesNo Sun Cream I agree that sun cream can be applied to my child (required) —Please choose an option—YesNo Emergencies I agree that in the event of an emergency staff can seek emergency medical advice or treatment (required) —Please choose an option—YesNo Hair Braiding I agree that my child can be involved in this activity if they have asked for it to be done (required) —Please choose an option—YesNo DVD Viewing I consent to my child watching a Certificate ‘U’ film (required) —Please choose an option—YesNo I consent to my child watching a Certificate ‘PG’ film (required) —Please choose an option—YesNo With changes in recent legislation we now need authorisation from parents as to who has legal parental responsibility and whom you authorise to take on legal parental responsibility in the event of your absence. This relates to authorisation of medication, outings, activities undertaken and any other documentation produced that requires a signature e.g. acknowledgment of accidents, administration of medication etc. Legal Parental Responsibility: Name Name Name Persons Authorised to take on Legal Parental Responsibility in the absence of the parent: Name Name Name Name The information you provide on this form will be shared within Loughborough College for administrative and health and safety purposes and with other organisations will include inspection and government or other regulatory bodies. The college will not divulge any information on this registration to any unauthorised agency without your prior written consent. At no time will any personal information about you or your child be passed on to organisations for marketing purposes. Because of the Data Protection Act 1988 we need you to sign the following “consent to process” clause. If you require any further information about this please contact the MIS Manager at the college. I agree to Loughborough College processing my child’s personal data or any other data the college may obtain from me or other people. I agree to the processing of such data as detailed above for any purposes connected with my child whilst on college premises, or for any legitimate reason. I have read the statement above relating to the Data Protection Act 1998 and agree. I Agree Click send to complete your child's registration.
