Registration Form (10.4)

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Reepham Nursery School’s Registration Form
The Pavilion, Stimpsons Piece, Reepham, NR10 4LL
Telephone: 01603-871586 Email: reephamnurseryschool@btconnect.com
Charity Number: 1028915

Child’s details

Child’s first name(s)

Surname

Name known as

Child’s full address

Gender

Date of Birth

Birth certificate seen and copy made
Yes □ No □

Family details

Name of parent(s)/carer(s) with whom the child lives:

Contact details 1 (including emergency information):

Parent/carer full name

Relationship to child

Daytime/work telephone

Mobile

Home telephone

Home address

Work address

Does this parent have parental responsibility for the child? Yes □ No □

Contact details 2 (including emergency information):

Parent/carer full name

Relationship to child

Daytime/work telephone

Mobile

Home telephone

Home address

Work address

Does this parent have parental responsibility for the child? Yes □ No □

Contact details 3 (including emergency information):

Parent/carer full name

Relationship to child

Daytime/work telephone

Mobile

Home telephone

Home address

Work address

Does this parent have parental responsibility for the child? Yes □ No □

Other person(s) with legal contact To be completed where those persons with parental responsibility are separated and an S8 Order is in place.

Name

Address

Contact telephone numbers

Relationship to child

What are the contact arrangements that we need to be aware of?

Emergency contact details if parents are not available Emergency contacts must be local.

Contact 1 – Name

Relationship to child

Address

Daytime/work telephone

Home telephone

Mobile

Contact 2 – Name

Relationship to child

Address

Daytime/work telephone

Home telephone

Mobile

Persons other than parent(s) authorised to collect the child Must be over 16 years of age. Please note that if the authorised person is not the person indicated on the daily signing in/out sheet, Staff will check before releasing the child.

Person 1 – Name
Relationship to child
Address
Daytime/work telephone
Home telephone						Mobile
Person 2 – Name
Relationship to child
Address
Daytime/work telephone
Home telephone						Mobile
Person 3 – Name
Relationship to child
Address
Daytime/work telephone
Home telephone						Mobile
Password for the collection of child by authorised persons

About your child
The following information will tell us a little more about your child. As your child settles with us, we will establish their starting points through observation and further conversation with you.

Does your child have previous experience of attending a childcare setting? If so, please specify:

Health and Development:

Has your child received the following immunisations? Please confirm and provide date of immunisations given.

Two months old

5-in-1 (DTaP/IPV/Hib) vaccine – diphtheria, tetanus, pertussis (whooping cough), polio and Haemophilus influenzae type b (Hib).

Yes □ No □

Date:

Pneumococcal (PCV) vaccine.

Yes □ No □

Date:

Rotavirus vaccine.

Yes □ No □

Date:

Three months old

5-in-1 (DTaP/IPV/Hib) vaccine, second dose – diphtheria, tetanus, pertussis (whooping cough), polio and Haemophilus influenzae type b (Hib).

Yes □ No □

Date:

Meningitis C vaccine.

Yes □ No □

Date:

Rotavirus, second dose.

Yes □ No □

Date:

Four months old

5-in-1 (DTaP/IPV/Hib) vaccine, third dose – diphtheria, tetanus, pertussis (whooping cough), polio and Haemophilus influenzae type b (Hib).

Yes □ No □

Date:

Pneumococcal (PCV) vaccine, second dose.

Yes □ No □

Date:

Between 12 and 13 months old

Hib/Men C booster – Haemophilus influenza type b (Hib), forth dose and meningitis C, second dose.

Yes □ No □

Date:

MMR vaccine – mumps, measles and rubella.

Yes □ No □

Date:

Pneumococcal (PCV) vaccine, third dose.

Yes □ No □

Date:

Two to three years

Flu vaccine

Yes □ No □

Date:

Three years and four months or soon after

MMR vaccine, second dose – mumps, measles and rubella.

Yes □ No □

Date:

4-in-1 (DTaP/IPV) pre-school booster – diphtheria, tetanus, pertussis (whooping cough) and polio.

Yes □ No □

Date:

For internal use: Has the child’s health record book been seen to confirm immunisation dates? Yes □ No □

Does your child have any on-going medical conditions? If so, please specify:

If yes, please specify which external agencies are involved e.g. Paediatrician, Consultant, Dietician, Speech and Language Therapist, etc:

Does your child require a health care plan? Yes □ No □

Is your child known to have any allergies or food intolerances? If so, please specify:

A risk assessment will be completed and kept on the child’s file for any known allergies or food intolerance as mentioned above.

What are your child’s dietary requirements? Please specify:

If your child is aged three years or over, does he or she have difficulty with any of the following:

Speaking and communicating

Yes

□

Listening and attending

Yes

□

Understanding simple instructions

Yes

□

Eating and drinking

Yes

□

Sitting and sharing a book

Yes

□

Walking and climbing

Yes

□

Rolling a ball

Yes

□

Holding a crayon

Yes

□

Socialising with adults and other children

Yes

□

Using the toilet

Yes

□

Putting on their shoes and socks

Yes

□

Any other concerns:

Does your child have any special needs or disabilities? If so, please specify:

Are any of the following in place for the child?

SEN action plan

Education, Health and Care Plan

What special support will he/she require in our setting?

Two year old progress check – children aged 24 – 36 months

If your child is aged between 24-36 months, has a two year old progress check already been completed for your child? Yes □ No □

Setting completing check

Date completed

As per the requirements of the Early Years Foundation Stage we will complete a progress check on your child between the ages of 24-36 months. We will ask you to be involved in completing the check and will discuss it with you.

Cultural background

How would you describe your child’s ethnicity or cultural background?

What is the main religion in your family (if applicable)?

Are there any festivals or special occasions celebrated in your culture that your child will be taking part in and that you would like to see acknowledged and celebrated while he/she is in [our/my] setting?

What language(s) is/are spoken at home?

If English is not the main language spoken at home, will this be your child’s first experience of being in an English-speaking environment?

Yes □

□

Does your child need a bilingual support plan?

Yes

□

If so, discuss and agree with the key person how we can work together to support your child when settling-in:

General information

What is your child’s usual sleep pattern?

Does your child have any food preferences?

Yes

□

Does your child have a pacifier i.e. dummy or thumb?

Yes

□

Does your child have a special toy or object they might bring with them?

Yes

□

What sort of things does your child enjoy doing at home, i.e. drawing or cooking?

What other information is it important for us to know about your child? For example, what they like, or what fears they may have, or any special words they use.

Details of professionals involved with your child

Name			Telephone
Address

Health Visitor (if applicable)

Name			Telephone
Address

Social Care Worker (if applicable)

Name			Telephone
Address

What is the reason for the involvement of the social care department with your family? NB If the child has a child protection plan, make a note here, but do not include details.We] will ensure these details are obtained from the social care worker named above and keep these securely in the child’s file.

Dentist (if applicable)

Name			Telephone
Address

Any other professional who has regular contact with the child

Name 1		Role
Agency		Telephone
Address
Name 2		Role
Agency		Telephone
Address
Name 3		Role
Agency		Telephone
Address

General parental permissions

Emergency treatment declaration

In the event of an accident or emergency involving my child I understand that every effort will be made to contact me immediately. Emergency services will be called as necessary and I understand my child may be taken to hospital accompanied by [the manager (or authorised deputy) for emergency treatment and that health professionals are responsible for any decisions on medical treatment in my absence.

Signed			Date
Printed name

For inhalers/auto-injectors (e.g. Epipens) only


I give permission for a named member of staff who has been appropriately trained to administer the inhaler/
Epipen or other auto-injector (supplied by me) to		(name of child).
The named staff are:
§
§
§
Signed	Date
Printed name

Suncream

I give permission for staff to administer hypoallergenic suncream to
	(name of child) when necessary and to record its use.
Signed		Date
Printed name

Short trip – general outings

Your child will be taken out of the setting as part of the daily activities. The venues used are detailed here:

Stimpsons Piece

I give permission for

(name of child) to take part in short trips or

general outings. I understand that individual risk assessments are carried out for each type of trip or outing taken and are available for me to see as required. For any major outings, I understand I will be informed and my specific consent obtained.

Signed			Date
Printed name

Photographs and Tapestry (our On-line Learning Journal)

As part of the on-going recording of our curriculum, and for children’s individual developmental progress records, we use ‘Tapestry’ which is an online learning journal. Staff regularly take photographs and write observations of the children during their play. Only tablets supplied by the setting are used for this purpose. At the end of your child’s time with us we are happy to provide a duplicate journal of your child for you if requested, [although this might incur a small charge to cover our costs]. Any photographs taken of children are deleted at the end of each week and all information is password protected and stored securely (see our TAPESTRY policy)
Website photos: – We have some wonderful photographs of our nursery and our children on the Nursery School Website www.reephamnurseryschool.co.uk The photographs of the children will only be used on the nursery school website (and not anywhere else, ie, facebook or any other kind of social media).

Animals

We may occasionally have supervised visits of animals to our setting:

§ Chicks/ducks
§ Small petting animals
§
We will ensure that our pets are healthy and fully inoculated, as appropriate, and that animals showing any signs of disease are treated. A risk assessment will be carried out for visiting animals, and parents informed.
Please state below any known allergies or aversion		(name of child) has to animals:

Signed	Date
Printed name

Key persons – Information for parents

Each child joining the setting will have a key person appointed to them. It will be the key person’s responsibility to ensure that your child receives the best possible attention whilst in our care and to ensure that their records are kept up-to date. [Your child’s key person may change as your child progresses through the setting. You will be notified of these changes.] Your child’s key person is your first point of contact for anything you wish to discuss about your child.

Your child’s key person will be

[Your child’s key ‘buddy’will be]

Date starting at

(name of provider)

Days and times of attendance

Are any fees payable? If so, note here

Has the settling-in process been agreed? Yes □ No □

If so, please specify:

Policies and procedures

I have been provided with details of Reepham Nursery School’s early years prospectus for parents, and its terms and conditions.The policies and procedures have been explained to me, including the Information Sharing Policy, and I understand that there may be circumstances where information is shared with other professionals or agencies without my consent.

Signed

Date

Printed name

Please sign below to indicate that the information given on this form is accurate and correct, and that you will notify us of any changes as they arise.

Parent name

Signed

Date

[For Reepham Nursery School]

Name of key person

Signed

Date

Name of manager

Signed

Date

Date of first review

Equalities monitoring form

Ethnicity – Gathered for monitoring purposes only. Parents are not obliged to complete this data.
White British	□	Pakistani	□
White Irish	□	Indian	□
White other	□	Asian other	□
Black British	□	Chinese	□
Black African	□	Chinese other	□
Black Caribbean	□	White and Black Caribbean	□
Black Other	□	White and Black African	□
Bangladeshi	□	White and Black Asian	□
Other please state

A child’s learning difficulties and disabilities status should be recorded according to the following categories:

No special educational need	□
SEN action plan	□
Education, Health and Care Plan	□

Providers should refer to the SEND Code of Practice for the Early Years (2014) for an explanation of the terms above.

I give permission for

(name of child) to have her/his photo taken and used for Tapestry and for it to appear in group Tapestry photos with other nursery children

and I give permission for photos for the website as per the above conditions.

Printed name