Sutherland Day Nursery application form

personal details
child's first name:
surname:
known as:
gender:	boy girl
date of birth:	(DD/MM/YY)
position in family (e.g. first child):
home address:
post code:
religion:
ethnic origin:
nationality:
language(s):
preferred start date:
details of any disabilities/special needs:

how did you hear about us?
please specify:

about your family
	mother/carer	father/carer
title
first name
surname
profession
home address (incl. postcode)
home tel.
mobile tel.
home e-mail
work address (incl. postcode)
work tel.
work e-mail
working hours
responsibilities	collecting child from nursery payment of fees being an emergency contact others (please specify)	collecting child from nursery payment of fees being an emergency contact others (please specify)

other contacts
contact 1
first name:
surname:
relationship to child:
address:
post code:
tel. no.:
mobile no.:
responsibilities:	collecting child from nursery being an emergency contact
contact 2
first name:
surname:
relationship to child:
address:
post code:
tel. no.:
mobile no.:
responsibilities:	collecting child from nursery being an emergency contact

medical details
allergies
does your child have any allergies?
if yes, please give details of cause, reactions and (if applicable) treatment:
dietary requirements
does your child have any special dietary requirements?
if yes, please give details:
medical conditions
does your child have any current medical conditions or needs?
if yes, please give details:
immunisations
has your child had any of the following immunisations? (please tick and give date)
bcg	date:
diphtheria	date:
hib	date:
mmr	date:
meningitis c	date:
poliomyelitis	date:
tetanus	date:
whooping cough	date:

medical contacts
doctor's details
name of GP:
name of surgery:
address:
post code:
tel. no.:
health visitor's details
name:
address:
post code:
tel. no.:
other agency details
name:
address:
post code:
tel. no.:

sessions (for children over 2 years old only)
	Mon	Tue	Wed	Thurs	Fri
full day, morning or afternoon only
extra hours (how many?)
meals (included in all session prices)
	Mon	Tue	Wed	Thurs	Fri
breakfast
lunch
tea

I will be making a payment for £ by (date)

I have read and agree to be bound by the Terms and Conditions.

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