Guidance Notes: Getting to Know you form

Guidance Notes: Getting to Know you form
This form is used by children’s centres to get to
know you and your family. Most of it will be selfexplanatory, such as your name and address
or the names of your children. Some requested
information needs more explanation, so
please see below for help in answering these
questions. Please complete the form carefully
and include as much information as possible.
The information that children’s centres collect
from your form and from records of your
attendance at activities helps to inform future
activities at the centre, as well as to provide
evidence of all the good work that happens at
your centre.
Questions marked with * are compulsory; you
must give us this information in order for your
children’s centre to record the information.
If you are unsure about these or any other
questions, please see a member of staff.
Are You a Lone Parent: We ask this so that
we can ensure our services are relevant to
everyone. Tick yes if you live alone with your
children or parent your children on your own
for the majority of the time.
Do You Smoke: We ask this so that we can
ensure our services are relevant to everyone.
Tick yes if you smoke at all and specify the
level of smoking below.
Do You Have a Registered Disability: Disability
is defined as having a physical or mental
impairment and that the impairment has a
substantial and long-term effect on their ability
to perform normal day-to-day activities. Please
speak to a member of staff if you are unsure
whether to tick yes or no.
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Do You Have Special Educational Needs
(SEN): Special Educational Needs refers
to a person who has learning difficulties or
disabilities that make it harder for them to
learn or access education than most people of
the same age. Often, SEN relates to children.
Please speak to a member of staff if you are
unsure whether to tick yes or no.
Do You Have Additional Needs: Additional
needs can be used alongside or instead of
Special Educational Needs. Please speak to a
member of staff if you are unsure whether to
tick yes or no.
Your Ethnicity: Ethnicity can include race,
culture, religion and nationality, which impact
on a person’s identity and how they are seen
by others. Ethnicity should be chosen from this
list: Afghan, White British, White Irish, White
Traveller of Irish Heritage, Gypsy/Roma, White
Eastern European, White Western European,
White Other, White & Black Caribbean,
White & Black African, White and Asian, Any
Other Mixed Background, Indian, Pakistani,
Bangladeshi, Other Asian, Black Caribbean,
Black African, Black Other, Chinese, Other.
Your Language: Please tell us about languages
other than English which are spoken in your
home.
Does Your Partner Work: We ask this so that
we can ensure our services are relevant to
everyone. We do not pass this or any other
employment information about specific people
on to anyone.
What Is Your Relationship To The Children
On This Form: We need to know the exact
structure of families in order to serve families
best. Please be specific about the relationships
of adults in the home to the children that live
there.
Pregnancy Number: Please tell us if this is your
first, second, third etc pregnancy.
Multiple Pregnancy: Please tell us if you are
pregnant with twins, triplets or any other
multiple pregnancy.
No. Of Weeks Pregnant At Birth (Gestation):
Please record the number of weeks pregnant
the birth mother was when the child was born.
Birth Weight: Please tell us the child’s weight
when they were born.
Permission For Photos To Be Taken: It is
important that you tell the centre this for
safeguarding reasons.
Tick boxes: There are three tick boxes above
the signature section. Please read these
carefully and tick any you agree with. Basically,
they are to receive information from the centre
and their partners about activities and to be
approached for your opinion on the way that
the centre runs. If you are unsure about these
or any other questions, please see a member
of staff.
Lancashire Children's Centres Registration Form
Getting to Know You and Your Family
MIS Number..................
Date.............................
Name & Organisation of Professional Completing form (if appropriate)...............................
INFORMATION MARKED WITH * IS ESSENTIAL AND MUST BE COMPLETED PLEASE
CONSULT THE GUIDANCE NOTES BEFORE COMPLETING
Your Family Details – Please provide details about your household
*Have you ever attended any children's centre?
Yes
No
*Please specify which children's centre:
*Family Address, including postcode:
Home Phone Number:
Mobile Number:
Email Address:
Agencies – Please provide details about any health professionals you are linked with
*Name of Health Visitor:
*Is your family registered with a doctor?
Yes
No
Yes
No
*Name of Doctor/Surgery:
*Name of Midwife:
*Is your family registered with a dentist?
*Name of Dentist/Surgery:
Carers Details – Please provide details about you, your partner or any other carers associated with the children listed on
this form – if there are more than two carers, ask for a follow-on additional sheet
YOU
*Your Title (please circle): Miss, Mrs, Mr, Dr
*First and Middle Names:
*Gender:
Male
Female
*Are you a lone parent?
*Do you smoke?
*Surname:
Yes
Yes
*Date of Birth:
No
*Do you have:
No
Please specify (Tick any that apply):
A registered disability:
Yes
No
Heavy smoker
Social smoker
Smoker
Special educational needs:
Yes
No
Never smoked
Trying to quit
Ex-Smoker
Additional needs:
Yes
No
*Are You (Tick any that apply):
*Your Ethnicity:
Employed Full Time
*Language (other than English):
Employed Part Time
Full Time Carer/Maternity Leave
In Training/Student
Unemployed
Self-Employed
Are you a childminder? :
Yes
No
Are you a Foster Carer? :
Yes
No
Retired
*Does your partner work?
Yes
No
*What is your relationship to the children on this form?: Birth Mother
Foster Carer
Adoptive Parent
Birth Father
Other Carer (e.g. parent's partner), specify:
YOUR PARTNER/OTHER CARER
*Your Title (please circle): Miss, Mrs, Mr, Dr
*First and Middle Names:
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Grandparent
*Gender:
Male
Female
*Are you a lone parent?
*Do you smoke?
*Surname:
Yes
Yes
*Date of Birth:
No
*Do you have:
No
Please specify (Tick any that apply):
A registered disability:
Yes
No
Heavy smoker
Social smoker
Smoker
Special educational needs:
Yes
No
Never smoked
Trying to quit
Ex-Smoker
Additional needs:
Yes
No
*Are You (Tick any that apply):
*Your Ethnicity:
Employed Full Time
*Language (other than English):
Employed Part Time
Full Time Carer/Maternity Leave
In Training/Student
Unemployed
Self-Employed
Retired
*Does your partner work?
Yes
Are you a childminder? :
Yes
No
Are you a Foster Carer? :
Yes
No
No
*What is your relationship to the children on this form?: Birth Mother
Foster Carer
Adoptive Parent
Birth Father
Grandparent
Other Carer (e.g. parent's partner), specify:
Pregnancy – Please give details if you or your partner are pregnant
*Are you or your partner pregnant?
st
No Due Date (if known):
Yes
nd
Pregnancy number (1 , 2 etc):
Multiple Pregnancy (if yes, please specify):
Children's Details – Please provide details about the children in your household - if there are more than two children, ask
for a follow-on additional sheet
st
1 Child
*First & Middle Names:
*Gender:
Male
*Surname:
Female
*Does the child have:
*Date of Birth:
No. of weeks pregnant at birth
*Birth Weight:
(Gestation):
Language (other than English):
A registered disability:
Yes
No
*Ethnicity:
Special educational needs:
Yes
No
Breastfed At:
Additional needs:
Yes
No
*NHS Number:
Emergency Contact Name:
Birth
6 wks
3 mth
6 mths
1 yr +
Nursery:
Is this child looked after by a Childminder?
Yes
No
*Do you give permission for photos to be taken and used in children's
Emergency Contact Number:
centre publicity, including on the internet?
Yes
No
nd
2 Child
*First & Middle Names:
*Gender:
Male
*Surname:
Female
*Does the child have:
*Date of Birth:
No. of weeks pregnant at birth
*Birth Weight:
(Gestation):
Language (other than English):
A registered disability:
Yes
No
*Ethnicity:
Special educational needs:
Yes
No
Breastfed At:
Additional needs:
Yes
No
*NHS Number:
Emergency Contact Name:
Birth
6 wks
3 mth
25
1 yr +
Nursery:
Is this child looked after by a Childminder?
*
6 mths
Yes
No
Do you give permission for photos to be taken and used in children's
Emergency Contact Number:
centre publicity, including on the internet?
Yes
No
Other Details
If one parent or carer lives at a separate
If there is any additional information which you would like to provide,
address, please provide it here:
please write here:
*Essential Information – Please read carefully, tick all appropriate boxes and sign the declaration (either parent/carer
can sign this form on behalf of the family)
*If you need to provide details of more than two carers or children, please ask for a follow-on additional sheet.
By signing the declaration below, I / We agree to information about myself and any dependents being kept on the
Lancashire County Council Children's Centres database and as a written record. I/We understand that this information
will be used for monitoring and evaluation purposes in connection with the provision of children's centre services. I/We
give permission for the Children's Centre to share this information with its partner agencies for those purposes only. The
data controller is Lancashire County Council and you can get information about how your information is used by writing
to the Data Protection Officer, PO Box 78, County Hall, Preston, PR1 8XJ, 01772 531116.
To ensure the Children's Centre are able to provide you and your child(ren) with the right support we may need to share
your information with partner agencies. Where possible we will discuss this you before we share any information.
I/we agree for the children's centre to share my information with partner agencies for the purpose of providing
support to myself or my child(ren).
Please tick here if you would like to receive information about events or activities organised by the children's centre.
Please tick here if you would like to receive information about events or activities organised by partners of the
children's centre.
Please tick here if you agree to being approached by the children's centre for feedback on services, for evaluation.
*Signed (Carer/Guardian) ........................................
*Signed (Carer/Guardian) ................................................
*Date ......................................................................
*Date ...............................................................................
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