Enrolment Form

About the Young Person

Full Name Date of Birth
Preferred Name School Name
Gender MaleFemale 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