Application Form Child Child's Surname * Child's Forename * Sex * ---BoyGirl Date of Birth - Day * ---12345678910111213141516171819202122232425262728293031 Month * ---JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemeberDecember Year * ---20072008200920102011201220132014201520162017201820192020 Address * Postcode * Parent/Carers (1) Name * Mobile No * Work No * Place of Work/Employer/Department * Home No * Email * Parent/Carers (2) Name Mobile No Work No Place of Work/Employer/Department Home No Email Required Start Date Day ---12345678910111213141516171819202122232425262728293031 Month * ---JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemeberDecember Year * ---20072008200920102011201220132014201520162017201820192020 Sessions required Monday AM Lunch PM Tuesday AM Lunch PM Wednesday AM Lunch PM Thursday AM Lunch PM Friday AM Lunch PM Kid's Club - Before and after care Monday AM PM Tuesday AM PM Wednesday AM PM Thursday AM PM Friday AM PM School bus If your child will be attending the 'Kid's Club' will you require use of the school bus? * Yes No If so, which primary school do/will they attend? Will you require care in the Kid's Club for half term time only? * Does your child currently attend another setting? * Yes No Lorna Barker (MA DIP SW) is our Special Educational Needs Co-ordinator. In accordance to our Equal Opportunities policy we aim to develop inclusive practice within our setting, it may be necessary to seek advice from other professionals from time to time on how to adopt our practice to meet individual needs. Please sign to acknowledge agreement with this. Additional Information Does your child have any allergies? * Does your child suffer from any medical conditions? * Has or is your child currently seeing any of the following professionals: Health Visitor Advisory Teacher Speech and Language Therapist Portage Educational Psychologist Occupational Therapist Paediatrician Physiotherapist Other If you answered yes to any of the above please give details ANY INFORMATION GIVEN WILL BE USED FOR THE SOLE USE OF THE NURSERY. ALL INFORMATION WILL REMAIN STRICTLY CONFIDENTIAL. Where did you hear about the nursery? * Have you received a Busy Bees Brochure? * Yes No Have you visited the nursery? * Yes No AFTER RECEIVING YOUR APPLICATION, IT WILL BE PLACED ON THE WAITING LIST. ONCE A PLACE BECOMES AVAILABLE WE WILL CONTACT YOU AND INVITE YOU IN TO HAVE A LOOK AROUND AND MEET THE STAFF.