Child Information

Child's name (required)

Name of the School the Child attends (required)

Which Out Of School Club would you like your child like to attend:
Chandlers FordHiltingburyMerdonScantabout

Parent/carer's name (required)
Mrs.Ms.Miss.Mr.Dr.

Parent/guardian/carer' Email address

Does this person have parental responsibility for the child?
YesNo

Emergency Contact Information

Contact Name 1: (required)
Mr.Mrs.Ms.Miss.

Relation to child:

Contact telephone number:

Address:

Postcode:

Contact Name 2: (required)
Mr.Mrs.Ms.Miss.

Relation to child:

Contact telephone number:

Address:

Postcode:

Other information required

Allergies

Has your child ever had an allergic reaction to ANYTHING?
YesNo

If yes, please provide full details:

Is your child’s Tetanus Jab is up to date?
YesNo

Food/Drinks (especially fruit and snacks)

Please tells us about the child's likes, dislikes and any special dietry requirements:

Activities

Please tells us what the child likes and dislikes doing and if there is anything that they are scared of

Language

Is English your child's second language?
YesNo

If yes, please tell us the child's first language

Religion

What is the main religion of the family environment of the child?

Festivals

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 care?

Health

Does your child have any of the following?:
Asthma/breathing problems YesNo
Skin conditions YesNo
Hearing difficulties YesNo
Sight difficulties YesNo
Speech difficulties YesNo
Any long term illness/conditions YesNo

If you have answered yes to any of the above, please give details below:

Name of doctor

Phone number

Address

Arrival/Departure
List the names of anyone (other than parents) who will be delivering/collecting your child.

Contact Name 1 (required)
Mrs.Ms.Miss.Mr.Dr.

Relation to child

Contact telephone number:

Address

Postcode

Contact Name 2 (required)
Mrs.Ms.Miss.Mr.Dr.

Relation to child

Contact telephone number:

Address

Postcode

Is there anyone who should not have contact with your child or is legally prevented?
YesNo.

If yes, please give details

Any other information

Is there anything else you think we should know in order to meet the needs of your child, or anything you have concerns about?

Signature

Signature (Please type your name):

Date