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
Name of Second Child *
Your answer
Child's Date of Birth
MM
/
DD
/
YYYY
Second Child's Date of Birth
MM
/
DD
/
YYYY
Child's ethnic Background
Your answer
Child's gender
Second 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
As a Charity WPFC receives funding which is given to support families on low income. Do you receive benefits?
Do you feel financially stressed?
Data Consent
Westbourne park Family Centre will keep your details secure and not share them with any other organisation without your consent. If you have any questions or want your data changed at any time, contact: info@westbourneparkfamilycentre.org.uk
Do you give permission for these details to be used anonymously as part of an evaluation of our services and their impact?
We occasionally take photographs for promotion and funding purpose. Do you give us permission to do this
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?
I understand the above statement and agree to the above terms
Print Name
Your answer
Date
MM
/
DD
/
YYYY
Submit
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