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 AMLunchPM Tuesday AMLunchPM Wednesday AMLunchPM Thursday AMLunchPM Friday AMLunchPM Kid's Club - Before and after care Monday AMPM Tuesday AMPM Wednesday AMPM Thursday AMPM Friday AMPM School bus If your child will be attending the 'Kid's Club' will you require use of the school bus? * YesNo 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? * YesNo 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 VisitorAdvisory TeacherSpeech and Language TherapistPortageEducational PsychologistOccupational TherapistPaediatricianPhysiotherapist 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? * YesNo Have you visited the nursery? * YesNo 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.