Child’s name:
Home address:
Home phone number:
Gender:MaleFemale
Date of birth:
Date first attended service:
Date ceased attending service:
Mother
Father
Name:
Work address:
Work number:
Mobile number:
Type of Booking:
Monday
Tuesday
Wednesday
Thursday
Friday
Preschool (Free ECCE Year)
9.00 am – 12.00pm – 5 days per week.9.00 am – 12.00pm – 5 days per week.
Preschool : ( Non ECCE year) Please tick days you would like your child to attend.
9.00 am – 12.009.00 am – 12.00
After school: Please write in the boxes the preferred time for your child to attend after school Between 1.40pm- 5.30pm
Name of any other person who may collect the child other than parent/guardian
I authorise
and/or
To collect my child
From Ballinrobe Bright Beginnings in the event of my absence.
Emergency Contact Person:
Address:
Phone No:
Relationship to Child:
Medical Information:
Details of family Doctor for your child:
I/We give permission to contact Doctor in case of illnessYesNo
Immunisation
Tick
B.C.G.
Meningitis C
6 in 1 ( Polio, whooping cough, HIB, Diphtheria, Tetanus and Hepatitis B)
6 in 1
M.M.R.
PVC
Booster
Has your child had any of the following:
Mumps:
YesNo
Measles:
Chicken Pox:
Whopping Cough:
Convulsions:
Asthma:
Allergies:
Does your child require additional special needs form?YesNo
Is your child on ANY medication?YesNo
If yes, please give details:
Permission:
I/ We hereby give my/ our permission for my/ our child to partake in walks and other outings outside the childcare grounds, on the understanding that the adult/ child ratio, as recommended by the insurance company will be adhered to at all times.YesNo
I/ We hereby give my/ our permission for my/ our child to be given Calpol or Nurofen when necessary, while in the care of the staff and under the supervision of the manager. (Only in an emergency and parents cannot be contacted.)YesNo
I/ We hereby give my/ our permission for staff to apply sun cream to my/ our child if staff feels it is necessary.YesNo
I/ We give permission for my/ our child to be administered first aid in case of emergency, on the understanding that it would be administered by a fully trained staff member.YesNo
