Enrolment Form

About the Young Person

Full Name Date of Birth
Preferred Name School Name
Gender  Male Female Class
EYFS Info (Pre-school and Reception only) Attach Photo
Name of Keyworker Contact

Primary Carer's Information

Primary Carer Name (* Required) Attach Photo Address
Home Phone Mobile Phone
Work Phone Email Address (* Required)
This person has Legal Responsibility   Relationship to Child
This Person has Parental Responsibility   Hours of Work

Secondary Carer's Information

Secondary Carer Name Attach Photo Address
Home Phone Mobile Phone
Work Phone Email Address
This person has Legal Responsibility   Relationship to Child
This Person has Parental Responsibility   Hours of Work

Emergency Contacts

Name I confirm this person has agreed to be contacted in case of an emergency and will be available of the time the child is in care  Agreed
Landline Mobile Phone
Name I confirm this person has agreed to be contacted in case of an emergency and will be available of the time the child is in care  Agreed
Landline Mobile Phone

Other Significant People 1/Authorised to Collect

Name Relationship
Address   This person has legal contact and/or responsibility Attach Photo

Other Significant People 2 / Authorised to Collect

Name Relationship
Address   This person has legal contact and-or responsibility Attach Photo

Other Significant People 3 / Authorised to Collect

Name Relationship
Address   This person has legal contact and/or responsibility Attach Photo

Special Requirements

Identification of special requirements does not automatically exclude your child from a place in our provision

Diagnosed Conditions - please select

 Anger Management Issues  Autism  Communication Requirements  Down's Syndrome
 My Child is part of a C.A.F.  My Child Requires a personal care plan

Medical Details

Child's Doctor's Name
Child's Doctor's Address
Child's Doctor's Contact
Child's Medical Number

Medical Conditions

ADHD   Asthma   Diabetes   Poor Vision  
Eplilepsy   Heart Disorder   Other
Comments

Allergies

 Adhesive Dressings  Animal Skin/Fur  Antibiotics  Insect Bites  Nuts  Pollen  Other
Comments

Up-to-date Immunisations

 Poliomyelitis  Tetanus  MMR

Medication

If you child has to take regular medication, a separate sheet will be required and will need to be updated frequently

 My Child has regular medication

Ethnicity

 White British  White Irish  White European  Other White Background  White Black Carribean  White Black African
 Other mixed  Black Caribbean  Black African  Other Black Background  Indian
 Pakistani  Bangladeshi  Chinese
 Other - please specify
Child's Religion Main Language Used at Home Other Languages Spoken

Religious or Cultural Practices. Please share any information you think is appropriate

Primary Carer's Work Pattern - If it is irregular

Any other information you feel is relevant. Such as interests, hobbies etc.

At The GAP Centre, the safety of our service users is paramount. Please list the names of people allowed to collect your child. Children will not be released to anyone otherthan those listed unless written consent is given

Declaration

I confirm that all information provided in the whole of this document is factual and correct at the time of signing. I will inform staff of any changes to this information as soon as possible.

Name

Signed

Date

Optional Research

 Internet Advertising

 Leaflet/Flyer/Poster  Newspaper Article/Advert  Internet Search  Council Information Service  Word of Mouth
 Friend Recommendation  Other Information Service  School

Tick all those that apply to your current situation

 Child Tax Credit
 Single Parent

Choose one of the following

 Full-Time Education
 Part-Time Education
 Education and Training