Holiday Club Registration Form

Child's Details

Forename(s) (required)

Surname (required)

Date of Birth (required)

Gender (required)

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

Special Educational Needs

Does your child have any Special Educational Needs (required)

If yes, please provide details below:

If yes, does your child have a Statement of Educational Needs maintained by the LEA

Dietary Requirements

Can your child eat anything? (required)


Please provide details:

Is your child vegetarian? (required)

Does your child have a food allergy or intolerance? (required)


Please provide details:

Medical Details

Does your child have any medical conditions? (required)


Please provide details:

Does your child take regular medication? (required)


Please provide details:

Does your child have any allergies (required)


Please provide details:

Are there any medical procedures that are prohibited by family religion or beliefs? (required)


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

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

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?

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?

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.

  1. Name

    Relationship to child

  2. Name

    Relationship to child

  3. Name

    Relationship to child

  4. 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)

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)

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)

Photographs for use on the Nursery Website

I agree to the use of photographs of my child appearing on the Nursery website (required)

Face Painting

I agree for my child’s face to be painted (required)

Hypoallergenic Plasters

I agree for hypoallergenic plasters to be administered to my child (required)

Pain and Fever Relief

I agree that my child can be given Calpol for pain and Fever Relief (required)

Allergic Reaction Relief

I agree to Piriton Syrup being administered to my child in the event of an allergic reaction. (required)

Sun Cream

I agree that sun cream can be applied to my child (required)

Emergencies

I agree that in the event of an emergency staff can seek emergency medical advice or treatment (required)

Hair Braiding

I agree that my child can be involved in this activity if they have asked for it to be done (required)

DVD Viewing

I consent to my child watching a Certificate ‘U’ film (required)

I consent to my child watching a Certificate ‘PG’ film (required)

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.