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 :
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 :
