St Richard Reynolds Breakfast Club
Registration Form
Name of Child
Surname ______________________
Forename ________________________
Middle names __________________
Known as_________________________
Age on entry _____years ___months
_
Position in family _______________
Date of birth ______________________
Male/Female______________________
Preferred Start Date: ____________
Please tick the boxes that apply to your package and preferred days.
Parent Package - Please tick your preferred Mornings 07.30am-08.50am
Or
The Supportive Package – Please tick your preferred mornings 08.15-08.45am
Monday
Tuesday
Wednesday
Thursday
Friday
PARENTS/GUARDIANS
Surname ______________________
Forename_____________________
Surname________________________
Forename _______________________
Address _______________________
Address_________________________
________________Postcode_______
_________________Postcode________
Home Telephone No_____________
Home Telephone No________________
Mobile________________________
Mobile____________________________
*E-mail address_________________________________
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Parental Responsibility
Name______________________________
Signed_____________________________
*Please indicate above who has Parental Responsibility.
EMERGENCY CONTACTS
Please give details of persons who live within the local area, who can be contacted
in an emergency, if parents are unavailable. Please place them in the order in
which you wish them to be contacted:
1. Surname_______________________ Forename _______________________
Relationship to child _________________________________________________
Address____________________________________________________________
__________________ Postcode________ Home Telephone __________________
Mobile ____________________________
2. Surname ________________________ Forename ______________________
Relationship to child __________________________________________________
Address_____________________________________________________________
______________________ Postcode__________ Home Telephone ____________
In case of an early collection please name the adults permitted to collect your child
from the Breakfast Club.
Name________________________
Name ________________________
Name________________________
Name_________________________
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HEALTH/WELFARE
Doctor___________________________Doctor’s Address______________________
________________________________Post Code________________ Health Visitor
_____________________________ Tel. No:________________________________
Medical Information
Does your child have any medical conditions we should know about. If so please
describe below.
_____________________________________________________________________
_____________________________________________________________________
Are there any medicines your child takes regularly eg for asthma or life threatening
conditions eg. allergic reaction requiring epi-pen?
_____________________________________________________________________
____________________________________________________________________
If yes, please contact the Breakfast Club for a copy of the Administering Medicines
Policy and to discuss this with the Proprietor/Manager. Please note that no
medicines can be administered without prior consent.
CONSENT TO EMERGENCY MEDICAL TREATMENT
I consent to any emergency medical treatment necessary during the course of my
child’s attendance at the breakfast club. I therefore authorise the teacher to sign
on my behalf any written form of consent required by the medical authorities
concerned, should the delay required to obtain my signature be considered by the
medical authorities likely to be prejudicial to my child’s health and safety.
Is there any food that your child must not eat?_____________________________
Languages spoken at home_______________________________
Ethnic origin (Please circle)
White
British
Irish
Traveller of Irish heritage
Gypsy/Roma
Other White background
Asian
Indian
Pakistan
Bangladeshi
Any other Asian background
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Black or Black British
Mixed
Caribbean
White and Black African
African
White and Asian
Any other black background
Any other mixed background
Chinese
Any other ethnic background _____________________________
Name of infant school you hope your child will attend
______________________________
Any other information which may be relevant to ensure that the Breakfast Club
meets your child’s needs
_____________________________________________________________________
_____________________________________________________________________
I have read the St Reynolds Breakfast Club prospectus and confirm acceptance of
the Terms and Conditions.
To register, please sign and date this form. Your place is secure once you pay your
non refundable registration fee of £30. Payment can be made by cash or by bank
transfer. We do not accept cheques. Our bank details are Lloyds TSB, Strawberry
Hill Pre-School, Sort Code 30-98-79, Account 24715260. Once your payment is
received then your place is secure. Please reference your payment with your
child’s full name.
Please return the form to of the office at St Richards Reynolds reception.
Signature of Parent/Guardian
Date
May we take this opportunity to welcome you and your child/children to St Richard
Reynolds Breakfast club
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