Early Years Registration Form
Westbourne Park Family Centre, Westbourne Park Baptist Church, Porchester Road, London W2 5DX
Tel. 020 7727 6019, Charity No. 1085070
Relation to Child *
Name *
Your answer
Email
Your answer
Address *
Your answer
Postcode *
Your answer
Which ward do you live in?
Home Tel:
Your answer
Mobile
Your answer
How did you hear about us?
Your answer
Name of Child *
Your answer
Child's Date of Birth
MM
/
DD
/
YYYY
Child's ethnic Background
Your answer
Child's gender
Are you a single parent?
Does your child have a disability?
Do you have a disability?
Parent/Carer ethnic background
Column 1
White-English/ Scottish/ N.Irish/ UK
White-Irish
White-Gypsy or Irish Traveller
Any other white background
African
Carribean
Other ethnic group
Any other Black/African/ Carribean
Mixed Ethic background
Indian
Pakistani
Bangladeshi
Chinese
Arab
Prefer not to say
Parent/Carer age
Parent/Carer first language
Your answer
Parent/ Carer gender
Parent/ Carer sexual orientation
Parent/Carer religion
Baseline Questions
We hope that these sessions will have a positive impact on parents. We will ask you the questions again in a few months to see if anything has changed as a result of you coming to the session
Please score from 0 to 10, where 0 is strongly disagree, and 10 is strongly agree with the statement
0
1
2
3
4
5
6
7
8
9
10
I have lots of friends
I feel part of the community in which I live
If I am worried about myself or my child I know who to ask
I enjoy being a parent
I find parenting very stressful
I can calm my baby when he/she is distressed
I understand what my baby is trying to tell me
I have people I can turn to locally if I need support
I feel confident about breast-feeding my baby
I feel isolated
In the past Week, on how many days have you listened to music with your child?
Column 1
Not in the past week
1 or 2 days
3-5 days
6-7 days
In the past Week, on how many days have you sung songs to or with your child?
Column 1
Not in the past week
1 or 2 days
3-5 days
6-7 days
In the past Week, on how many days have you danced with your child?
Column 1
Not in the past week
1 or 2 days
3-5 days
6-7 days
In the past Week, on how many days have you done other musical activities with your child?
Column 1
Not in the past week
1 or 2 days
3-5 days
6-7 days
In the past Week, how often have you read to your child?
Column 1
Not in the past week
1 or 2 days
3-5 days
6-7 days
Data Consent
We occasionally take photographs for promotion and funding purposes. If you do not want your child or yourself to be photographed, please tick here
Do you give permission for the details of your dependants and yourself to be kept on the Westminster Children Centres Database?
Do you give permission for these details to be used anonymously as part of an evaluation of our services and their impact?
Would you like to receive email updates on upcoming events and opportunities from Westbourne Park Family Centre, Paddington Development Trust and Creative Futures?
Are you interested in volunteering to suport these sessions?
Westbourne park Family Centre will keep your details secure and not share them with any other organisation without your consent for us to hold our process your data at any time by contacting info@westbourneparkfamilycentre.org.uk
Where appropriate we will share this data with our delivery partners, Paddington Development Trust and Creative Features.
I understand the above statement and agree to the above terms
Print Name
Your answer
Date
MM
/
DD
/
YYYY
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