Early Days - Booking Form

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Booking

BOOKING FORM

Please fill in all parts of the booking form:

Child’s Personal Details

Child’s Surname Name:	Date of Birth:
Child’s First Name	Home Tel No:
Child’s Middle Name	Correspondence Address:
Affectionately Known as:
Date of Commencement:	Finishing Date:

Parent’s/Guardian Personal Details

Mother’s Name:	Father’s Name
Work Address	Work Address

Work contact number	Work contact Number
Home contact number	Home contact number
Home Address:	Home Address:
Email address:	Email address:
Who Does the child live with	Collection password

Designated people to collect child (other than parents. Guardian

1.Name:	2. Name:
Tel No:	Tel No:
3. Name	4. Name
Tel No:	Tel No:

Nominated emergency contact persons

1.Name:	2. Name:
Address	Address:
Tel No 1	Tel no 1:
Tel No 2	Tel No 2:

Personal Details

Family Doctor: Tel No:

Address:

Immunisation Record Please tick and enter date

B.C.G

Yes/No

Date

--/--/----

--/--/----

Diphtheria

Yes/No

Date

--/--/----

--/--/----

Tetanus

Yes/No

Date

--/--/----

--/--/----

Whooping cough

Yes/No

Date

--/--/----

--/--/----

Polio

Yes/No

Date

--/--/----

--/--/----

MMR

Yes/No

Date

--/--/----

--/--/----

Meningitis C

Yes/No

Date

--/--/----

--/--/----

General Medicine Consent:

To administer general medicines such as Calpol or Paralink, written permission is necessary in order to comply with insurance requirements. Please sign below if you agree to the administration of general medicines by the staff, if they think it necessary.

Signed: Parent/Guardian

Signed Nursery Manager

Date:

Does your child suffer from any medical conditions and/allergies?

Please outline details and special requirement:

Does your child suffer from any hearing and/or speech difficulty

Please outline details and special requirement:

Does your child suffer from any special dietary requirements?

Please outline details and special requirement:

Does your child use pet language for special comforts toys?

Please outline details and special requirement:

Name of siblings and or close personal relationships in your child’s life

Please outline details and special requirement:

Additional information that might help us get to know your child better:

Permission for Outings and sun-cream application

I/We herby give my/our permission for: To partake in walks and other outings outside the nursery grounds, on the understanding that the adult/child ratio (as recommended by the insurance company) will be adhered to at all time.

Signed: Parent/Guardian

Signed Nursery Manager

Date:

Permission for Nutrition

I/We herby give my/our permission for: To consume ALL food items displayed on our menu,

(dated --/--/--/), and other food that Early Days and/or consultant nutritionist deem fir from time to time

I/we are not aware of any conflicting allergies my/our child has

Signed: Parent/Guardian

Signed Nursery Manager

Date:

Accident and/or Emergency Authority

I/We herby give my/our permission to the management of Early Days to act on my/our behalf in case of emergency or accident and to take such action as may be necessary for the welfare of my/our child

Signed: Parent/Guardian

Signed Nursery Manager

Date:

Photography/Broadcast and Video permission

I/We herby give my/our permission for my child to be photographed, broadcast or video recorded, under the supervision of Early Days management

Sined: Parent/Guardian

Signed Nursery Manager

Date:

ANTICIPTATED DAYS: MON TUE WED THUR FRI

ANTICIPTATED Hours per Day: From:___________ To: ___________

Any other relevant information:

Signed _______________________ Dated: _______________