Child's Name *

First Name

Last Name

Child's D.O.B *

MM

DD

YYYY

Siblings *

Does your child have a sibling that currently attends the setting?

Yes

No

Address *

Your Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Child's start date *

MM

DD

YYYY

Guardian 1 Name *

First Name

Last Name

Do you live at the same address as your child? *

Yes

No

Guardian 1 D.O.B *

MM

DD

YYYY

Guardian 2 Name *

First Name

Last Name

Do you live at the same address as your child? *

Yes

No

Guardian 2 D.O.B *

MM

DD

YYYY

Collection Authorisation 1 Name

First Name

Last Name

Collection Authorisation 2 Name

First Name

Last Name

Collection Authorisation 3 Name

First Name

Last Name

Collection Authorisation 4 Name

First Name

Last Name

Doctors Name

First Name

Last Name

Doctors Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Has your child ever accessed any other Early Years Settings? *

Yes

No

Not known

Does your child currently attend any other Early Years Settings? i.e. nursery, childminder, pre-sctool etc. *

Yes

No

Not Known

Are there any specific Health considerations? *

Yes

No

Not Known

Does your child have any allergies or have previously been allergic to anything (including food)? *

Yes

No

Not Known

Does your child have or previously had any medical conditions? *

Yes

No

Not Known

Does your child require an inhaler or epilepsy-pen? *

Yes

No

Not known

Is your child using long-term medication?

Yes

No

Not known

Does your child have any complex medical needs, special education needs or an identified disability? *

Yes

No

Not known

Is there any other agency involved with your child, for example speech therapist? *

Yes

No

Not known

Does your child/family have an Early Help Assessment (EHA)? Who is the lead practitioner? *

Yes

No

Not Known

Does your child have a named social worker? *

Yes

No

Not Known

Does your child have any dietary requirements *

Yes

No

Not Known

Allergies *

Please list any allergies that your child has

Gluten

Peanuts

Tree Nuts

Celery

Mustard

Eggs

Milk

Sesame

Fish

Crustaceans

Molluscs

Soya

Sulphites

Lupin

Other

None

8 Week Vaccinations

6 in 1 Vaccine

Rota Virus

MenB

12 Week Vaccinations

6 in 1 Vaccine (2nd Dose)

PCV

Rota Virus (2nd Dose)

16 Week Vaccinations

6 in 1 Vaccine (3rd Dose)

MenB (2nd Dose)

1 Year Vaccinations

Hib/MenC

MMR

PCV (2nd Dose)

MenB (3rd Dose)

2 Year Vaccinations

Flu

3 Year Vaccinations

Flu

3 Year 4 Month Vaccinations

MMR (2nd Dose)

4 in 1 Pre School Booster

4 Year Vaccinations

Flu

Vaccination Opt Out *

If you have decided not to give your child one or more of the above routine childhood vaccinations, please tick the declaration below. Declaration

If my child has not received any of the above jabs I understand that other parents at the nursery will be made aware that there is a child within the setting has not received the vaccinations (no personal details will be disclosed).

Do you consent to emergency non-prescribed medication should your child need it? *

I/We give permission for my child to receive a measured dose of paracetamol, Calpol & antihistamine in accordance with the Medicines and Healthcare Products Regulatory Agency (MHRA) guidance if they have a fever and appear distressed or unwell. I/We understand that I/We will be contacted prior to the dose being administered to confirm any prior dosage and to arrange collection of my/our child. Paracetamol will not be administered to children less than 3 months old. PLEASE NOTE – Emergency Paracetamol will not be given until the child’s temperature reaches 38 degrees please see medication policy for further details.

Yes

No

Do you consent to us applying a plaster should your child need one? *

If your child were to injure themselves in setting and there was an open wound we would ask their permission to apply a plaster to cover it up to prevent any germs or dirt getting into it. We would also need your permission to do so.

Yes

No

Do you give permission for us to share information with other early years settings? *

I / We give permission for Kabuki Childcare Centre to contact the other settings my / our child currently or previously attended so that information regarding their development and welfare can be shared.

Yes

No

Do you give permission for us to share information with other health colleagues and outside agencies? *

The Statutory Framework for the Early Years Foundation Stage 2017 requires us to review your child’s progress between two and three years old and provide parents with a short-written summary. During this progress review, we will contact your child’s health visitor, this will allow us to identify any developmental delays which needs early intervention. In order to do this, it is helpful if you share with us at regular intervals what is recorded in your child’s health record (red book). There may also be other occasions where we may need to share information relating to your child’s health and welfare with their named health visitor. I / We give permission for Kabuki Childcare Centre to contact my child’s health visiting team so that information regarding my / our child’s health, development and welfare can be shared or joint developmental assessments can be arranged. I also give permission for any reports to be copied to my health visitor and where relevant passed to my child’s next setting / school.

Yes

No

Do you give consent for your child's photograph to appear within the nursery? *

Yes

No

Do you give consent for your child's photograph to appear within external printed media (posters/leaflets/local media) *

Yes

No

Do you give permission for your child's photograph to appear on online & social media platforms (Facebook/Instagram/Kabuki website)? *

Yes

No

Do you give permission for your child's photograph to appear on another child's ParentZone? *

Yes

No

Do you give permission for your child to go on trips and outings away from the setting? *

As part of the learning experience that Kabuki Childcare Centre provides we feel it is of great importance for children to be able to go to the local park, library or shops.

Yes

No

Do you give permission for us to apply sun cream if your child requires it? *

In order to protect children from the sun Kabuki Childcare Centre will provide sun cream for all children throughout the day. (Please apply at home before coming to nursery) The type of sun cream will be factor 30, however the brand may differ so please ask your child’s key person if you would like full details.

Yes

No

Do you consent to us providing emergency treatment to your child if needed? *

I/We give permission for my/our child to receive appropriate medical attention and treatment should an emergency occur. I/we understand that I will be contacted as soon as possible about the emergency or accident and that Kabuki Childcare Centre staff may accompany my child to hospital in my absence if necessary.

Yes

No

Do you give permission for us to brush your child's teeth should your child need it? *

Yes

No

Date *

MM

DD

YYYY