Child Entry Application Name of Child * First Name Last Name Date of Birth Religion Childs 1st Language Other languages Has your child previously attended another setting? YES NO Is your child disabled? YES NO Special Access Requirements? YES NO Start Date required: MM DD YYYY Parents/Carers holding parental responsibility: Names: Home Address Address 1 Address 2 City State/Province Zip/Postal Code Country Mobile Number: (###) ### #### Work Name/Tel: (###) ### #### Email * Persons authorized to collect your child: * Name/relationship to the child/telephone number: In case of an emergency please contact: * (if different from authorized persons) Password: (must be given to any persons collecting your child who is NOT on the list) Important Medical Conditions * (e.g.) allergies Injections Up to date * YES NO Childs Doctor * Name/Address and Tel Childs Dentist * Name/Address and Tel Childs Health Visitor * Name/Address and Tel Toilet Requirements: Special Dietary Requirements: Special Educational Needs Requirements: Parental Consent I give my consent for my child to receive any medical treatment that is urgently required. Parental Consent I give consent for my child’s photographs to be displayed within the nursery. Parental Consent I give consent for my child to be taken on outings with nursery. Parental Consent I agree to photographs of my child being published in the local newspaper on certain occasions. Parental Consent I understand that any carer who suspects that a child in their care is being abused or neglected has a duty to report this to Children’s Social Care/sharing information. Parental Consent I agree to Smartypants Nursery applying henna/face paint to my child during parties. Parental Consent I give permission for my child’s photo to be displayed on Smartypant’s Facebook page/Website. Parental Consent I agree to informing management of any concerns and not putting these on any form of social media sites as Smartypant’s management aim to protect the privacy and rights of the nursery, staff and families. Parental Consent I give permission for my child to have sun cream/nappy cream applied at the nursery if required. Parental Consent I understand that CCTV cameras are installed throughout the nursery for safeguarding purposes. Parental Agreement For the provision of free early years childcare (15hrs & 30 hrs) * Parent name and Date of birth National Insurance Number Childs NHS Number Does your child take up FEE at any other childcare provider? * YES NO Days per week Please select the days you would like your child to attend during the week. Monday Tuesday Wednesday Thursday Friday Hours * Please write what hours your child will attend. (This will be subject to availability) 2 Years Funding Letter Reference: * *Letter must be submitted to nursery along with child’s Birth Certificate 11 digit free 30 hrs code: * I confirm that all the information provided is accurate and true. I understand and agree to the conditions set out in this document and I authorize Smartypants exclusive childcare to claim free early years education funding as agreed above on behalf of my child. In addition, I agree that the information I have provided can be shared with Lancashire County Council to enable this provider to claim the Early Years Pupil Premium (EYPP) on behalf of my child. Sign and Date: Thank you for your application, the team will process this and be in touch!
