REGISTRATION FORM

Child’s photograph here
REGISTRATION FORM
Please complete ALL areas
Child’s First Name:
Middle names:
Surname:
Date of birth:
Gender – M/F
Religion:
Language spoken at
home:
Ethnic origin:
Parent/Carer’s 1 name and title (Mr/Mrs etc):
Parent/Carer’s 2 name and title (Mr/Mrs etc):
Address:
Address:
Postcode:
Postcode:
Contact telephone number 1:
Contact telephone number 1:
Contact telephone number 2:
Contact telephone number 2:
Email:
Email:
Date of birth:
Date of birth:
NI number:
NI Number:
Relationship to child:
Relationship to child:
Security Password:
Security Password:
Emergency
Contact?
Bill Payer?
Parental
Responsibility?
Authorised
Pick-up?
Emergency
Contact?
Bill Payer?
Parental
Responsibility?
Other Contact 3 - Name and title (Mr/Mrs etc):
Other Contact 4 - Name and title (Mr/Mrs etc):
Address:
Address:
Postcode:
Postcode:
Contact telephone number:
Contact telephone number:
Relationship to child:
Relationship to child:
Security Password:
Security Password:
Emergency
Contact?
Bill Payer?
KK Registration Form – 25 Sep 15
Parental
Responsibility?
Authorised
Pick-up?
Emergency
Contact?
Bill Payer?
Parental
Responsibility?
1
Authorised
Pick-up?
Authorised
Pick-up?
Does your child/family have social services involvement/or has had in the past? Yes/No
If so – what is reason for involvement?
Name:
Based at:
Tel:
Email:
Does your child have any special educational needs or disabilities?
Yes/No. If Yes, please give details:
Does your child attend another setting e.g. nursery/childminder?
Yes/No. If Yes, please give details.
Name:
Address:
Contact key person:
Tel:
Permission to share information - Yes/No
Email:
How did you hear about us – tick which apply:
Other – Please state how you heard about Kamelia Kids:
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
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Website
Radio
Flyer
Word of Mouth
Health Professional
Local paper/community magazine
Admin Fee
A non-refundable administration fee of £30 per child on
acceptance of a place (excluding children only accessing
their Free Entitlement Funding and 2 year old funding when
they enter the nursery) will be charged.
Acceptance:
The terms and conditions are considered to be fair and
reasonable. In the event of any term found by a Court of
Law to be unreasonable then the clause shall be removed
but the agreement shall remain in full force and effect.
The parent/guardian has read and understands the terms
and conditions contained in this form and undertakes to be
bound by the same.
KK Registration Form – 25 Sep 15
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ATTENDANCE SCHEDULE - to be completed with Nursery Manager
Term time only –
please tick if applicable
Sessions
Duration
Times
Breakfast
1hr
8am - 9am
Morning
3hrs
9am - 12pm
Short day
5hrs
9am - 2pm
Medium day
7.5hrs
9am - 4.30pm
Full day
10hrs
8am - 6pm
Mon
Tues
Wed
Thurs
Fri
Kool Kids Clubs:
Breakfast
8am - 9am
3pm - 4.30pm
After School
3pm - 6pm
Pickups from West Park School
I give permission for my child to be collected from school on the days selected as
above.
Signature:
Date:
This registration form incorporates the terms and conditions which are shown below. Upon signing this form the parents
are deemed to have read, understood and agreed the same. For fees please refer to separate sheet.
Signature and date
(Parent/Carer 1)
Signature and date
(Parent/Carer 2)
Print name:
Print name:
OFFICE USE ONLY
Admin fee paid
Yes/No
2 year old or FE form completed and attached
2 year old number:
Birth certificate seen
Yes/No
Yes/No/Not applicable
Birth Certificate Number:
Agreed Start date:
Print name:
(on behalf of Kamelia Kids)
Signature
Data uploaded onto Parenta database – Yes/No
Entry number:
Data Protection: In compliance with current UK Data Protection legislation, any information you provide here will be kept secure and treated
confidentially. The data collected will only be used by Kamelia Kids and will not be disclosed to any external sources without your prior
consent.
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IMPORTANT – PARENT/CARERS CONSENT
Child’s full name
Area of Consent
First Aid
Statement
Parent/Carer Signature
Date
I hereby give consent for my child to be given any
emergency first aid treatment as deemed necessary by the
staff of the nursery.
I will inform the staff of any known allergies that may affect
treatment.
Medication
I give my consent for any prescribed medication that I have
given to the staff to be administered to my child by them
and agree to completing the necessary form(s) to enable
this to happen.
Sun Cream & Baby Wipes
I give consent for sun protection/baby wipes and nursery
sun-cream to be used on my child by the nursery staff. I
understand brands may vary but will always be suitable for
use. Please provide your own if preferred.
Photographs, Videos & Social
Media
I give consent for my child to be photographed/videoed
whilst in nursery or on outings for Nursery displays
internally – Yes/No.
I give consent for my child to be photographed/videoed
whilst in nursery or on outings for Nursery on the website
Yes/No.
Collection by other named
person
I also give consent for my child to appear in
photographs/videos taken by or for other parents to mark
special events (such as birthdays, events and Christmas
parties).
I may need someone other than myself to collect my child
from nursery. I will inform a staff member at the beginning
of the session. The following named individuals may collect
my child;
1.
2.
My password is:
This is for emergency purposes only.
If someone not named above has to collect my child and I
have not signed the collection book.
Off-site outings
I give permission for Kamelia Kids staff members to take my
child off site for walks or local outings.
Outside agencies
On a regular basis we have outside agencies i.e. Health
visitor, Speech & Language, Physiotherapist and
Occupational Therapists, Portage, Sensory support,
Educational Psychologists and Nurseries etc. visiting to see
individual children at the nursery.
We will inform you if anyone is visiting your child, but we
would like your written permission, to pass on any relevant
information about your child to the professional concerned.
Date Protection
This will include sharing information in your child’s Learning
Journal/ 2 year progress check
I accept that Kamelia Kids will store information about my
child, and understand it will only be used for nursery
purposes. I am happy for my email address to be used for
nursery communication.
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IMPORTANT – MEDICAL INFORMATION
Child’s full name:
Doctor’s name and practice address
Doctor’s telephone number
Immunisations/vaccinations – please list
Health Visitor name & contact telephone number
Any allergies – please list
Any other useful information
If necessary, please add on a separate sheet
The parent/carer agrees to collect a child who becomes ill whilst in the care as soon as possible & abide by our exclusion period. They also agree to inform
us if their child contracts an infectious disease or head lice. The nursery staff do their best to comfort children who become ill during the day & we will
inform you as necessary. We will also advise you of any outbreaks of infectious diseases or cases of head lice.
Parent/Carer signature
Print name:
KK Registration Form – 25 Sep 15
Date:
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TERMS AND CONDITIONS
Parents/Carers agree to:
Registration/Acceptance/Termination/Variation
1. Pay a non-refundable administration fee of £30 per child on acceptance of a place (excluding children only accessing
their Free Entitlement Funding and 2 year old funding when they enter the nursery). This fee covers administration and
settling sessions;
2. After acceptance of the offer by the parent/carer either party may terminate this agreement by giving 4 weeks’
notice in writing to the Nursery Manager during which time the child may continue to attend the nursery. In the
event of the child being withdrawn immediately then 4 weeks fees will be due in lieu of notice;
3. If in the reasonable opinion of the Nursery Manager it is considered that the continued presence of the child would be
detrimental to the health, safety or well-being of the child or other children of the nursery or the staff then the nursery
may serve notice to the parent/carer or a request for the child to be immediately removed from the nursery and the
provision of 4 weeks’ notice shall not apply;
4. Any variation of this agreement must be confirmed in writing by both the parent/carer and the Nursery Manager.
5. Any reduction to sessions requires 4 weeks’ notice in writing;
Payment of Nursery Fees:
6. Pay the nursery fees in advance, on the first day of each month, by cash, cheque (payable to ‘Kamelia Kids’), internet
banking (bank details will be on the invoice), standing order (form supplied on request) or by a voucher scheme through
your employer, please use your child’s name as a reference on any form of payment;
7. Failure to comply could result in sessions being suspended until full payment is made. If the payment of fees remain
outstanding for more than 2 weeks then the nursery may serve 2 weeks’ notice in writing to terminate this contract.
Upon termination of this contract the child shall cease to be admitted to the nursery and the nursery’s notice to so
terminate shall be regarded as a formal demand for all outstanding monies;
8. Part sessions will be charged at the full rate. Sessions missed due to sickness or holiday will be charged at the full rate.
Fees are also charged for Public and Bank holidays;
9. The nursery reserves the right to increase the fees at any time upon giving 4 weeks written notice of the proposed
increase;
10. If the nursery has to close for reasons beyond our control refunds of fees will not be given unless at the discretion of the
management;
11. Arrive and collect the child on time. Repeated late collection or time beyond 15 minutes will be charged at £10 per
quarter hour or part thereof. Persistent lateness may result in sessions being suspended;
Sickness & Medication:
12. Inform the nursery if the child has had any form of illness within 24/48 hours of their session and respect the nursery’s
decision on whether or not to admit the child. Understand that if the child has experienced any form of vomiting or
diarrhoea within 48 hours of their session, they must NOT be sent to the nursery;
13. Inform the nursery of any medication prescribed by the doctor and give written permission (including dosage
instructions) for the staff to administer the medication if required;
Other:
14. Give permission for the child to be observed and assessed by key staff whilst at Kamelia Kids Day Nursery;
15. Understand that Kamelia Kids Day Nursery cannot take responsibility for the loss or damage to any personal belongings;
16. Provide suitable emergency contacts and update when necessary;
17. Ensure your child is appropriately dressed for nursery e.g. coat, suitable shoes;
18. Provide suitable healthy snack and/or lunch for your child;
19. Inform the nursery of any agencies working with the child/family i.e. social services;
20. Drive and park considerately and safely – avoid parking in the staff car park and emergency vehicle area;
21. Abstain from smoking outside the nursery building or adjacent grounds;
22. Use appropriate language in or around nursery grounds (no swearing).
23. Parents and visitors are requested not to use their mobile phones whilst on the premises.
Early years Free Entitlement and 2 years funding
Kamelia Kids Day Nursery is currently registered to receive statutory Free Entitlement and 2 year old funding subject to
availability for 38 weeks per year.
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STATISTICAL DATA
Please complete the following details where applicable – by placing a
√ alongside.
This information is used purely for statistical purposes only.
Nationality:
Language :
Religion:
Ethnic Origin:
African
American
Australian
Brazilian
British
Canadian
Chinese
Dual Nationality
Dutch
French
German
Indian
Irish
Japanese
Polish
Portuguese
Spanish
Chinese
Creole
Creole / English
Dutch
English
Esperanto
French
German
Greek
Italian
Japanese
Polish
Portuguese
Somali
Spanish
Baptist
Buddhist
Catholic
Christian
Church Of England
Church Of Scotland
Hindu
Islam
Jehovah Witness
Jewish
Methodist
Muslim
None
Shinto
Sikh
Asian Bangladeshi
Asian Indian
Asian Other
Asian Pakistani
Black African
Black African Other
Black African Somali
Black Caribbean
Black Other
Chinese
Declined
Greek Or Greek Cypriot
Gypsy/Roma
Irish
Mixed Other
Mixed White And Asian
Mixed White And Black
African
Mixed White And Black
Caribbean
Not Obtained
Other
Other Vietnamese
Refused
Traveller Of Irish
Heritage
Turkish/Turkish
Heritage
Unknown
White British
White European
White Other
I agree that this information is up to date and accurate and accept that it is my responsibility to inform the
nursery of any changes to this information.
Signature:
Date:
Print Name:
KK Registration Form – 25 Sep 15
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