Nursery Registration Form – Dickory Docks Day Nursery

Please fully complete the form below WHEN A PLACE HAS BEEN OFFERED with all the details so we can create a formal contract for you to sign at settling-in. We must also receive a non refundable registration admin fee to process the information, and a deposit, as specified in the email requesting this form to be completed.

If you complete this form and have not been offered a place, we will not be able to process the information or necessarily offer a place.

- Step 1 of 6

Name of child to enrol *

Date of Birth *

Proposed Start Date *

Child's gender *

Male
Female

Who does the child normally live with? *

Mother / Parent 1
Father / Parent 2

Who has legal contact with the child? *

Mother / Parent 1
Father / Parent 2

Who has parental responsibility? *

Mother
Father

Does your child attend another setting? *

Please answer Yes if child is leaving a setting to come to Dickory Docks, or if your child will continue to attend another setting while attending Dickory Docks

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 Nationality *

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 *

Grant Funding *

No Funding
Baby 9 to 23 months 15hrs
Baby 9 to 23 months 30 hrs (Sep 2025)
Toddler 2 Year 15 hrs
Toddler 2 Year 30 hrs (Sep 2025)
Pre School 15 hours Universal Funding
Pre School 30 hrs Extended Funding

Grant Funding Code *

Please enter the funding code issued by Early Years. It is normally 11 digits, and usually begins with 5xxxx. If child is not grant funded, please enter "No Grant"

Grant Funding Stretch Period *

Please select the grant period to use used. If attending School Term Time Only, it is 38 weeks. Stretched 51 weeks means 15hrs will become 11.17hrs per week and 30 hours will become 22.35hrs per week. Also, it is NOT POSSIBLE to attend 38 weeks, and then add extra regular out of term attendance due to staffing.

Nursery Meals *

Please note that the nursery includes meals in the price quoted, except where a free place is available. These places are limited

Special Dietary Requirement *

Please give details *

Price quoted *

Please enter the weekly amount agreed with the nursery for the attendance. If no quote has been given yet, please state "No quote"

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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 Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Mother Work Telephone

Mother National Insurance Number *

Please enter your NI Number

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 Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Father Work Telephone

Father National Insurance Number *

Please enter your NI Number

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 needs hearing aid *

Please give details *

Child wear's glasses *

Please give details *

Child NHS Number

10 digit NHS Number

Child has asthma *

Please give details *

Child has a confirmed allergy *

Please give details *

Child has regular medication *

Please give details *

Any other difficulties? *

Please give details *

Other medical conditions 1

Epilepsy
Eczema
Hay Fever
Sickle Cell/Thalassemia

Other medical conditions 2

Diabetes
Heart Condition
Febrile Convulsions
Cystic Fribrosis

Immunisations 1

Whooping cough
HIB Meningitis
Diptheria
Measles

Immunisations 2

Tetanus
Mumps
Polio
Rubella

Infant Paracetamol *

Permissions to administer

Infant Paracetamol Dosage *

2.5ml (3 - 6 months)
5ml (6 - 24 months)
7.5ml (2 - 4 years)

Dosage to administer

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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 *

First

Last

Emergency Contact's relationship to the child 1 *

Please provide details 1 *

Emergency Contact 1 Home Number

Emergency Contact 1 Mobile Number *

Emergency Contact's Name 2 *

First

Last

Emergency Contact's relationship to the child 2 *

Please provide details 2

Emergency Contact 2 Home Number

Emergency Contact 2 Mobile Number *

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Additional Permissions *

Staff allowed to take my child for local walks with correct adult supervision
I give permission photographs to be taken of my child, using the nursery iPads/Tablets which may then be used for nursery records, displays, and in the newsletter. I am aware that the nursery has no control of the newsletter once sent out.
Photographs to be taken of my child alongside other children within the nursery which will be added to online learning journals of my child and others if a group photo.
For group photographs to be used in local newspaper releases.
For staff to observe my child as part of the Early Years Foundation Stage to plan and support learning opportunities.
For trainee/ students within the nursery to observe my child as part of their studies whilst maintaining confidentiality
For staff to apply nappy cream / Sudo cream / Suncream which I will provide
For my child’s individual records to be shared with outside agencies, including medical staff if hospital treatment is required. A member of nursery staff would accompany the child
I give permission for my email to be used to assign me an account on online Tapestry journal (for my child's progress)
I give permission for my child's photo to be added to the nursery Facebook page 'Dickory Docks Educational Day Nursery' to show activities, trips, and events. I am aware that they nursery have no control of these pictures once uploaded to Social media
I give consent to the holding of personal data for the parents and the 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 agree to Online Learning Journals being used for EYFS developmental learning journeys.
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 agree to Online Learning Journals being used for EYFS developmental learning journeys.
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

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Feedback *

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