Holiday Club Registration Form – Dickory Docks Day Nursery

Please complete this form for us to assess the suitability and availability of a place in our Holiday Club. Once received, we will check for spaces, and send a confirmation via email, and invite you to make a payment to confirm the place. Payment must be received in full within 1 day to confirm the place, else it will be offered to another child.

Payments made for a place will not be refunded for any reason.

- Step 1 of 6

Name of child to enrol *

Date of Birth *

Proposed Start Date *

Child's gender *

Male
Female

Who has legal contact with the child? *

Mother / Parent 1
Father / Parent 2

Who has parental responsibility? *

Mother
Father

Please provide details *

Setting Name, Contact Number, Contact Name, and Attendance Times

Child's home address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Child's First Language *

Ethnicity *

Please select one of the option matching closet to your ethnicity

Child Collection password *

The password can be any word you like and can remember. If someone else collects your child, they will be challenged by staff for the same password. If we have not been told, we may still contact you to confirm.

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Attendance

We reserve the right to withdraw a childcare place if attendance is different to that in place offer. All sessions are subject to availability, and can change at any time. Attendance must be 2 or more days. Standard sessions are from 8.00am to 6pm, and includes all meals.

Mon AM *

Mon PM *

Tue AM *

Tue PM *

Wed AM *

Wed PM *

Thu AM *

Thu PM *

Fri AM

Fri PM *

Special Dietary Requirement *

Please give details *

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Parents / Guardians Information

Mother / Guardian Name 1 *

First

Last

Mother Email *

Confirm Email

Parent 1 Gender *

Male
Female

Mother Date of Birth *

Mother Contact *

Mother first language *

Mother Occupation *

Mother Work Telephone

Parent 1 Named on Child's Birth Certificate *

Father / Guardian Name 2 *

First

Last

Father Email *

Confirm Email

Parent 2 Gender *

Male
Female

Father Date of Birth *

Father Contact *

Father first language *

Father Occupation *

Father Work Telephone

Parent 2 Named on Child's Birth Certificate *

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Child's Medical Information

Child's GP Surgery and contact number *

Child has been seen by a hospital consultant *

Please give details *

Child has asthma *

Please give details *

Child needs hearing aid *

Please give details *

Child has any eyesight condition(s) *

Please give details *

Child has a confirmed allergy *

Please give details *

Child has regular medication *

Please give details *

Any other difficulties, such as mobility? *

Please give details *

Other medical conditions 1

Epilepsy
Eczema
Hay Fever
Sickle Cell/Thalassemia

Immunisations 2

Tetanus
Mumps
Polio
Rubella

Immunisations 1

Whooping cough
HIB Meningitis
Diptheria
Measles

Other medical conditions 2

Diabetes
Heart Condition
Febrile Convulsions
Cystic Fribrosis

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Emergency Contacts

Please provide an alternative contact person in case of emergency. Emergency contacts must be over the age of 18 and capable of caring for the child if you are unavailable.

Emergency Contact's Name 1 *

Emergency Contact's relationship to the child 1

Please provide details 1

Emergency Contact 1 Mobile Number

Emergency Contact's Name 2

Emergency Contact's relationship to the child 2

Please provide details 2

Emergency Contact 2 Mobile Number

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Additional Permissions *

Staff allowed to take my child for local walks with correct adult supervision
Photographs to be taken of my child alongside other children within the nursery.
In emergencies, my child's medical record can be shared with medical staff if hospital treatment is required.
Permission to hold personal data for parent(s) and child in accordance with the GRPR Regulations, as stated in the standard terms and condition attached. (If "N", we will not be able to provide any care service)

Clickable Document Link

Click the link below to open the document:

Please Click to read the Standard terms and Conditions (Opens in a separate Tab)

Declaration 1 *

I/WE have read and understood and agree to the Terms and Conditions set out in this contract and subject to reasonable change from time to time.
I/WE declare that all the information provided in this contract is true and any liability arising to non-disclosure specifically medical information of the child is EXCLUDED.
I/WE understand that in signing this, we are entering into a contract to pay for the services provided by the Nursery to our Child.
I/WE confirm that we have parental responsibility for the child and that no other person’s consent is required for the Child to attend the Nursery.
I/WE understand that any carer who suspects that a Child in his or her care may have been abused or neglected has a duty to report this to the social care services working in line with the Local Safeguarding Children’s Board.
I/WE have read and understood all the standard terms, and GDPR regulations regarding personal data

Signature Parent 1 *

Clear Signature

I state all information given in this form is accurate and has been checked by me

Declaration 2 *

I/WE have read and understood and agree to the Terms and Conditions set out in this contract and subject to reasonable change from time to time.
I/WE declare that all the information provided in this contract is true and any liability arising to non-disclosure specifically medical information of the child is EXCLUDED.
I/WE understand that in signing this, we are entering into a contract to pay for the services provided by the Nursery to our Child.
I/WE confirm that we have parental responsibility for the child and that no other person’s consent is required for the Child to attend the Nursery.
I/WE understand that any carer who suspects that a Child in his or her care may have been abused or neglected has a duty to report this to the social care services working in line with the Local Safeguarding Children’s Board.
I/WE have read and understood all the standard terms, and GDPR regulations regarding personal data

Signature Parent 2

Clear Signature

I state all information given in this form is accurate and has been checked by me

Rating *

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Feedback *

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