Child Details

Child's Name * First Last

Gender *

Date of Birth * / DD / MM YYYY

Home Address (Primary) *

Street Address

Line 2

City

County

Postal Code

Country

Preferred Nursery Slot *

Morning (AM) Afternoon (PM) Either

Contact 1 Details

Contact 1 Name * First Last

Contact 1 Email Address *

Contact 1 Address *

Street Address

Line 2

City

County

Postal Code

Country

Contact 1 Home Telephone Number *

Contact 1 Mobile Telephone Number *

Contact 1 Work Telephone Number (If Applicable)

Relationship to Child (e.g Grandma, Uncle, Neighbour, family friend) *

Contact 2 Details

Contact 2 Name First Last

Contact 2 Email Address

Contact 2 Address

Street Address

Line 2

City

County

Postal Code

Country

Contact 2 Home Telephone Number

Contact 2 Mobile Telephone Number

Contact 2 Work Telephone Number (If Applicable)

Relationship to Child (e.g Grandma, Uncle, Neighbour, family friend)

Other Information

Previous School or Nursery

Surgery Name *

Surgery Phone Number *

Surgery Address *

Street Address

Line 2

City

County

Postal Code

Country

Conditions or Concerns

Allergies

Dietary Requirements

Please advise if your child is supported by any outside agencies. For example, social care, CAF, Speech and Language

Travel Arrangement *

Bicycle Car/Van Taxi Car Share Bus Walk Other

Name and ages of other school age children in the family

First Language *

Bengali Cantonese Creole/Patois English Gufjrati Hindi Italian Mandarin Arab Other Punjabi Portuguese Urdu Turkish Smail Spanish Polish Romanian Other

Ethnic Background *

Afghan African Asian Albanian Any other Asian Background Any other Black Background Any other Ethnic Group Any other Mixed Background Any other White Background Arab Other Asian and Any other Ethnic Group Asian and Black Asian and Chinese Bangladeshi Black - African Black - Angolan Black - Congolese Black - Ghanaian Black - Nigerian Black - Sierra Leonean Black - Somali Black - Sudanese Black and Any other Ethnic Group Black and Chinese Black Caribbean Black European Black North American Bosnian - Herzegovinian Chinese Chinese and Any Other Ethnic Group Croatian Egyptian Filipino Greek Greek Cypriot Greek / Greek Cypriot Gypsy Gypsy / Roma Hong Kong Chinese Indian Information Not Yet Obtained Iranian Iraqi Italian Japanese Kashmiri Other Kashmiri Pakistani Korean Kosovan Kurdish Latin / South / Central American Lebanese Libyan Malay Malaysian Chinese Mirpuri Pakistani Moroccan Nepali Other Asian Other Black Other Black African Other Chinese Other Ethnic Group Other Gypsy/Roma Other Mixed Background Other Pakistani Other White British Pakistani Polynesian Portuguese Refused Roma Serbian Singaporean Chinese Sri Lankan Other Sri Lankan Sinhalese Sri Lankan Tamil Taiwanese Thai Traveller of Irish Heritage Turkish Turkish / Turkish Cypriot Vietnamese White British White Cornish White English White Irish White Scottish White Welsh White and Any Other Asian Background White and Any Other Ethnic Group White and Asian White and Black African White and Black Caribbean White and Chinese White and Indian White and Pakistani White Eastern European White European White Other White Western Europe Yemeni I do not wish an ethnic background to be recorded

Do you agree that if we are unable to contact you in an emergency, that the Head or Deputy may act and make decisions on your behalf. *

I agree

Signed *

Today's Date *