Child's Name(Required)
First
Last
Nursery(Required) Please select a nursery Berryfields (Aylesbury) Brinds Well (Orpington) Cedar Park (Twyford) Cedars (Leighton Buzzard) Cherry Trees (Cranfield) Crescent (Birmingham) Devonshire (Chiswick) Edwalton (Nottingham) Edwinstowe Close (Cambridge) Emscote House (Leamington Spa) Field House (Bucks) Grasshoppers (Aylesbury) Grasshoppers (St Albans) Green Park (Reading) Greengables (Sandhurst) Hampstead Gate (Milton Keynes) Hertford Barns (Hertford) River View (Hertford) Highbury Lodge (Hitchin) Highfield (Birmingham) Julia Durbin (Oxford) Knowle Green (Staines) Lavenders (Bedford) Lime Grove (Hemel Hempstead) Maples (Winchester) Meadow View (Newport Pagnell) Mulberry (Maidenhead) Nature Trails (Rugby) Nene Valley (Northampton) Nursery on the Green (Redbourn) Nursery on the Green (Southall) Pennypot (Chobham) Rowan Tree (Welwyn Garden City) Sandfield (Oxford) Seabrook (Luton) West Cambridge (Cambridge) West Downs (Winchester) Westwood (Coventry) Willows (Aylesbury) Windermere (Kettering) Windmill Hill (Swindon) Woodberry (Winchmore Hill) Woodlands (Barnet) Woodlands (Milton Keynes)
Have you been offered a place by your nursery?(Required) Please select Yes No
If you have not been offered a place please do not complete this form. You can find the registration form on your chosen nursery's webpage.
Emergency Contacts Emergency contact 1(Required)
First
Last
Emergency contact 2
First
Last
Collection Statement I, the Parent / Carer, give the following named persons authorisation to collect my child from Nursery in my absence:
Name
First
Last
Authorised to collect without prior confirmation Please select Yes No
Would you like to add someone else? No Yes
Name
First
Last
Authorised to collect without prior confirmation Please select Yes No
Would you like to add someone else? No Yes
Name
First
Last
Authorised to collect without prior confirmation Please select Yes No
Medical Statement
Please confirm yes or no to the following statements I confirm that my child has previously had Paracetamol e.g. ‘Calpol’ and that no adverse reactions were noted.(Required) Please select Yes No
I confirm that my child has previously had Ibuprofen e.g. ‘Calprofen’ and that no adverse reactions were noted.(Required) Please select Yes No
I confirm that my child has previously had Chlorphenamine Maleate e.g. ‘Piriton’ and that no adverse reactions were noted.(Required) Please select Yes No
Please indicate your preference for Childbase to provide the following medication 'Paracetamol' e.g Calpol(Required) Single dose for high temperature following indicated dosage requirements
Please select Yes No
‘Ibuprofen’ e.g. Calprofen(Required) Single dose for high temperatures following indicated dosage requirements
Please select Yes No
‘Chlorphenamine Maleate’ e.g. Piriton(Required) Single dose to relieve allergic symptoms following indicated dosage & age requirements
Please select Yes No
Childbase supplies the following items for your Child at Nursery Please indicate whether you are happy for us to do so
Nappies(Required) Please select Yes No n/a
Nappy cream(Required) Please select Yes No n/a
Baby wipes(Required) Please select Yes No n/a
Formula milks(Required) Excluding following-on Milks. Up to the age of 12 months.
Please select Yes No n/a
Sun Cream(Required) Child friendly Factor 30 UVA/B 5 star rated or equivalent
Please select Yes No
If you have answered no to any of the above please indicate what you will provide below:
Medical and Dietary Information Does your child suffer from any allergies/intolerances?(Required) Please select Yes No
If yes, please indicate below:
Does your child have any dietary requirements e.g. vegetarian, or any religious/cultural dietary requirements e.g. no pork?(Required) Please select No Yes
If yes, please indicate below:
Does your child have any on-going medication or medical needs?(Required) Please select Yes No
If yes, please indicate below:
Please indicate below if there is any medical treatment(s) you do not wish your child to have in emergency situations: We will pass this information to the Emergency Services
Does your child have any birth marks or similar?(Required) Please select Yes No
If yes, please indicate below:
6-in-1 vaccine dose 1 (8 weeks)(Required) Please select No Yes
6-in-1 vaccine dose 2 (12 weeks)(Required) Please select No Yes
6-in-1 vaccine dose 3 (16 weeks)(Required) Please select No Yes
Pneumococcal (PCV) vaccine dose 1 (12 weeks)(Required) Please select No Yes
Pneumococcal (PCV) vaccine dose 2 (12 months)(Required) Please select No Yes
Hidden
Pneumococcal (PCV) vaccine dose 3 (1 year)(Required) Please select No Yes
Rotavirus vaccine dose 1 (8 weeks)(Required) Please select No Yes
Rotavirus vaccine dose 2 (12 weeks)(Required) Please select No Yes
MenB dose 1 (8 weeks)(Required) Please select No Yes
MenB dose 2 (16 weeks)(Required) Please select No Yes
MenB dose 3 (1 year)(Required) Please select No Yes
Hib/MenC dose 1 (1 year)(Required) Please select No Yes
MMR dose 1 (1 year)(Required) Please select No Yes
MMR dose 2 (3 years 4 months) Please select No Yes
4-in-1 pre-school booster (3 years 4 months)(Required) Please select No Yes
If you have answered no, and it is not age related, please indicate why this is:
Safeguarding Statement Safeguarding(Required) In certain circumstances it may be necessary that personal information is displayed for the protection of the child involved. In these cases we ask for your permission to display the information. e.g. Allergy Awareness, Medical Information, Religious Preferences
Please select Yes No
External Support and Advice(Required) I agree that staff can seek external advice and/or support for my child from Early Years
professionals such as Inclusion Officers and/or Heath Visitors
Please select Yes No
Outings and Trips Authorisation(Required) I agree that the nursery can take my child on reactive outings and trips e.g. walks to the
park or local shops
Please select Yes No
iConnect
iConnect/ Parentzone Observations and Photography I understand that Childbase use iConnect to track my child’s development which is mandatory as per the Early Years Foundation Stage (EYFS) requirements.(Required) Please select Yes
I am happy for photos to be uploaded to iConnect as part of my child's observations.(Required) Please select Yes No
I give consent for my child to appear in small group photos which may be used on other children’s iConnect observations which are viewable by their parents. Please note that these images cannot be removed at a later date.(Required) Please select Yes No
Email/ Text Message Statement I agree to receive information from Childbase via email(Required) Please select Yes No
This will primarily be nursery newsletters and important company updates
I agree to receive text messages from Childbase to keep me informed of key events and in emergency situations(Required) Please select Yes No
Data Protection Statement
Nursery Management System I understand that data pertaining to me and my child will be taken and stored digitally on a secure server, as described above.(Required) Please select Yes
CCTV and Photography Policy
Internal CCTV and Photography Do we have your authority to take photos of your child to use in internal displays?(Required) Please select Yes No
I understand CCTV is used on the premises for security and training purposes(Required) Please select Yes
Photography for External Marketing and Publicity Do we have consent for your child to have photos taken by Childbase that may be used for company publicity purposes, such as posters, leaflets, websites etc.?(Required) Please select Yes No
Do we have consent for your child to have photos taken by Childbase that may be used for company publicity purposes on social media e.g. Facebook, Instagram, LinkedIn and Twitter?(Required) Please select Yes No
Photography Marketing Photography
Marketing photos, if consent is given above, will only be used for a period of 3 years from the date the photo was taken. You can ask Childbase Partnership, by emailing info@childbase.com, to stop using your child’s images at any time, in which case they will not be used in future marketing materials but may continue to appear in publications already in circulation. Social media images will no longer be used but cannot be removed permanently.
Do we have consent for your child to have photos taken by an approved photography company which will be made available for purchase by you? (All photographers will hold a clear DBS (Disclosure Barring Service) prior to being allowed into the Nursery. The Nursery Manager will check and record the relevant information which will be held at Nursery)(Required) Please select Yes No
Parent/Guardian Name(Required)
First
Last
Signature(Required) By signing I agree that the information provided is accurate to the best of my ability
