Section 1 - Confidential Admission Form
Please complete all sections carefully and submit by the very latest 11th July.
Child's Details
Legal Forename *
Middle Name
Legal Surname *
Preferred Forename
Preferred Surname
Date of Birth *
MM
/
DD
/
YYYY
Gender *
Current Home Address and Postcode *
Home Phone Number
Email Address *
Family Details and Emergency Contacts
Parent/Carer 1 Details
What is Parent/Carer 1's relationship to the child? *
Does the Parent/Carer 1 have parental responsibility? *
Parent/Carer 1's Forename *
Parent/Carer 1 Surname *
Parent/Carer 1 address if different from above
Parent/Carer 1 home phone number if different from main phone number
Parent/Carer 1 work phone number
Parent/Carer 1 mobile phone number
Parent/Carer 1 home email address if different from above
Parent/Carer 1 work email address
We are asking for 4 emergency contacts - when would you like the above contact called in an emergency of if you're child is unwell? *
Required
Parent/Carer 2 Details - This would be the second emergency contact
What is Parent/Carer 2's relationship to the child? *
Does the Parent/Carer 2 have parental responsibility? *
Parent/Carer 2 Forename *
Parent/Carer 2 Surname *
Parent/Carer 2 Address if different from above
Parent/Carer 2 home phone number if different from above
Parent/Carer 2 work phone number
Parent/Carer 2 mobile phone number *
Parent/Carer 2 home email address *
Parent/Carer 2 work email address
When would you like the above contact called in an emergency of if you're child is unwell? *
Required
Other Local Emergency Contacts
Name *
Relationship to child *
Home phone number *
Work phone number
Mobile phone number *
Home email address *
Work email address
When would you like the above contact called in an emergency of if you're child is unwell? *
Required
Name *
Relationship to child *
Home phone number *
Work phone number
Mobile phone number *
Home email address *
Work email address
When would you like the above contact called in an emergency of if you're child is unwell? *
Required
Medical Information
Doctor's Name *
Surgery Address *
Surgery Phone Number *
Does your child have any allergies? *
Required
If your child has an allergy, please briefly describe it below and whether your child has an epi-pen
Is there any other medical information you wish to bring to our attention? Please briefly describe below.
Ethnic and Cultural Background
Country of Birth *
Language spoken predominantly at home *
Nationality *
Religion *
Please tell us the names of people who will regularly be collecting your child and their relationship to your child. *
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