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Registration  Form



Name of child............................................................................................        Date of birth........................................

Address........................................................................................................................................................................

......................................................................................................................................................................................

Parents/Guardians name/s and Telephone No ...........................................................................................................

Other Contact No.........................................................................................................................................................

Email Address ….........................................................................................................................................................

Who has parental responsibility for your child ?...........................................................................................................

Who is authorised to pick up your child ? …................................................................................................................

………………………………………………………………………………………………………………………………………………………………………………….

Any other Contact names or numbers in the event of us being unable to contact any of the above ?

…..................................................................................................................................................................................

Name, Address and Tel No of Doctor  ........................................................................................................................

…..................................................................................................................................................................................

Immunisation Details  ..................................................................................................................................................

Any other information …

Dietary……………………………..................................................................................................................................

Medical……………………………………………………………………………………………...........................................

Allergies ……….….........………………………………………………………………………………………………….........

Language spoken at home.......................................................................................................................................…

Religion/Belief……….............………………………………………………………………………………………………….


I, the parent/guardian of the child named above give my permission for the child to attend hospital with a member of Breton’s staff in an emergency at the playgroup leader’s discretion. I have read, understood and agree to the preschool policies and procedures.

Parent/Guardian’s signature..............................................................................................Date.................................................................

Any other information or concerns  (Please use other side if required)  ......................................................................…………………….........................................................................................................................................................

claire.lakin1@btopenworld.com      /     07595 603498



Staff Use - Birth Certificate Confirmed                            Start Date :


   


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