Playsafe Registration

Child Details

Child's First Name
Child's Last Name
Name Child is Known by
Date of Birth
Gender	Male Female
Address


Postcode
Telephone Number
E-Mail Address

Club Requested

Emergency Contact Details

Please ensure that you provide contact numbers for at least 3 people who can be contacted in an emergency.

Mother's First Name
Mother's Last Name
Employer Address



Telephone No.
Mobile No.
Does this parent have parental responsibility	YES NO

Father's First Name
Father's Last Name
Employer Address



Telephone No.
Mobile No.
Does this parent have parental responsibility	YES NO

Please ensure you supply a Head Office number if work numbers go to voicemail when in meetings, in case of emergency

Other emergency contacts - must be different to details given above

Emergency Contact 1
Telephone Number
Relationship to Child

Emergency Contact 1
Telephone Number
Relationship to Child

Commencement

Date of commencement requested at club

Which school does your child attend?
Which class are they in?

Please tell us below if your child takes part in any other school related after school activities (e.g. chess club) which may mean we have to collect them at a later time.

	Monday	Tuesday	Wednesday	Thursday	Friday
Which Club
Where is it held

Child's Doctor
Address



Telephone No.
Are all immunisations up to date	YES

Special & Specific Needs

Has/does child suffer from -

Asthma
Epilepsy
Convulsions/fits
Hayfever/Eczema
Diabetes
Food Allergies
Other

Please give details

Does child have any allergies

(Please make careful note of action required)

Does child have an Epipen

(If yes - book a date for meeting to complete the individual health care plan - between manager, key worker, parent and the named health visitor of the setting as Epipen Policy and Procedure states) For child's health and welfare they will only be allowed in the setting with their medication.

YES

Date for Meeting

Any special Medicines required

Any special Diets required

Any Dietary Dislikes

Any special Drinks required

Child's Religious persuasion and Culture

Details of any procedures that are prohibited for medical, religious, cultural or other reasons

Man or First Language spoken at home

Any special areas for Help

How did you hear about us
Specify

I agree to the staff seeking medical attention for my child in an emergency if I cannot be contacted	YES NO
I consent to the staff agreeing medical attention for my child in an emergency if I cannot be contacted by a medical officer	YES NO

Please note that no unauthorised person will be allowed to collect your child.
No child under the age of 16 is allowed to collect a child from the club.
Fees must be paid one month in advance. If fees are not paid one month in advance, your child's place will be 'suspended'. This means that your child cannot attend the club until payment has been made and there will be no after school collection of child.
In the event of cancellation of a place by a parent/guardian, fees still need to be paid.

Please press submit and you will be taken to a secure page to pay the £15.00 registration fee to secure a place on the waiting list. PLEASE NOTE: Registration fee is non-refundable

A member of the admin team will contact you to confirm availability for the place you have requested

There is a two week turnaround for new applications. Minimum is 7 days.

Playsafe Clubs Registration

Please note this registration form is for our clubs.

To register for our Jancett Nurseries please complete the registration form here