application-form

- Step 1 of 6

Which setting are you applying to? *

Child's Details

Name *

First

Last

Known As

Date of Birth *

Nationality *

Religion *

Ethnicity *

Lanauages Spoken *

Gender *

Male
Female
Unborn

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Telephone

Nursery Sessions

Preferred Start Date *

Sessions Required

Please indicate which sessions you require

Monday

Full Day (8am to 6pm)

Tuesday

Full Day (8am to 6pm)

Wednesday

Full Day (8am to 6pm)

Thursday

Full Day (8am to 6pm)

Friday

Full Day (8am to 6pm)

Parents/Guardian 1 details

Parent / Guardian 1 Name *

First

Last

Relation to Child *

Address (if Different from child)

Address Line 1

City

State / Province / Region

Postal Code

Email *

Home Phone *

Mobile Phone *

Work Phone

Occupation *

Responsibility (Tick all that apply) *

Parental responsibility
Collection of Child
Fees

Parent / Guardian 2 Details

Parent / Guardian 2 Name *

First

Last

Relation to Child *

Address (if Different from child)

Address Line 1

City

State / Province / Region

Postal Code

Email *

Home Phone *

Mobile Phone *

Work Phone

Occupation *

Responsibility (Tick all that apply) *

Parental responsibility
Collection of Child
Fees

All fee invoices will be emailed to a nominated account, please state the e-mail address below. *

Additional Emergency Contacts

Emergency Contact 1 *

First

Last

Relation to Child *

Mobile Phone *

Alternative contact number

Address *

Address Line 1

City

State / Province / Region

Postal Code

Emergency Contact 2 *

First

Last

Relation to child *

Mobile Phone *

Alternative contact number

Address *

Address Line 1

City

State / Province / Region

Postal Code

Additional persons who may collect your child

Please list below any other persons who may occasionally/regularly collect your child. The parent must give prior notice to the Nursery of any arrangement made.

Names (please also indicate relation to child.)

Single Line Text

Password *

This password will be used in an emergency, if someone not on the list collects the child.

Medical information

Name of GP *

Address of GP *

Address Line 1

City

State / Province / Region

Postal Code

Has your child had any of the following immunisations?

1st Diphtheria, Tetanus, Whooping Cough, Polio, Hib , Meningitis C
2nd Diphtheria, Tetanus, Whooping Cough, Polio, Hib , Meningitis C
3rd Diphtheria, Tetanus, Whooping Cough, Polio, Hib , Meningitis C
1st Measles, Mumps, Rubella
2nd Measles, Mumps, Rubella

Please provide dates of any immunisations indicated above.

Does your child have any allergies? *

Is your child taking any medication? Please also state reason. *

Does your child have any special educational needs? *

Any other information ( e.g. dietary/religious etc.)

Emergency treatment

I / we agree to senior staff taking the necessary steps to ensure that our child receives the best and most appropriate care, attention and treatment should there be an emergency or accident in the environment or whilst my child is on an authorised outing. The Nursery will make effort to inform the parents of an emergency or accident as soon as possible after the event but they have permission to accompany my child to a hospital in case of a serious accident, in my absence. I give permission for staff to contact the emergency services in my absence. I also give permission for the senior staff in charge of the provision to authorise hospital staff to administer essential treatment until my arrival.

Electronic Consent *

I accept - Parent/Guardian 1
I accept - Parent/Guardian 2

By selecting the 'I accept' checkbox above, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. By selecting "I Accept" checkbox you consent to be legally bound by this Agreement's terms and conditions.

Permissions

I/We give consent to have any emergency First Aid Treatment as deemed necessary by the staff of the nursery. *

I/We give consent for sun protection to be applied to my child by nursery staff (I will provide a labelled sun cream bottle). *

I/We give consent for any nappy cream or other cream to be applied to my child (I will provide these if necessary). *

I/We give consent for baby wipes to be used on my child. *

I/We give consent to use plasters/bandage/dressings on my child. *

I/We give consent for my child to be photographed/videoed whilst at nursery or outings for internal displays and child development records. *

I/We give consent for my child to be photographed whilst at nursery and for this to be used on our website/promotional material (please note we do not give out the names of the children) *

I/We give permission for staff members to take my child off-site for walks and outings, given that the correct child to staff ratio’s still apply. *

I/We agree/consent to my child being given Calpol in the event of him/her needing it for temperature control or severe teething pains. I understand that I will be contacted before my child receives Calpol and will collect them as soon as possible in the case of high temperatures. *

In the event that I cannot be contacted, I agree that Calpol can be administered if my child has an excessive temperature, as long as other attempts to cool the child down have not worked. (e.g. remove clothing to under garments, given water to drink). *

Electronic Consent *

I accept - Parent/Guardian 1
I accept - Parent/Guardian 2

Data Protection

In compliance with current UK Data Protection Legislation, any information you provide will be kept secure and treated confidentially. The Data collected will only be used by Wetherby House Montessori and will not be disclosed to any external sources except regulatory authorities without your prior consent.

Disclaimer

In signing this form, the parents are deemed to have read, understood and agreed to the terms and conditions. Please request a copy if you have not already received one.

Identity Verification

Please bring with you - • Original Birth Certificate and Red Health Book for Child • Photo ID and Proof of Address of Parents

Electronic Consent *

I accept - Parent/Guardian 1
I accept - Parent/Guardian 2