Enrolment form If you are human, leave this field blank.Basic DetailsWe need some details about your child and family. We have a legal obligation to collect and process this information in accordance with The Early Years Foundation Stage (Welfare Requirements) Regulations 2012 and therefore we do not require your consent for the first section of this form. Where information to be supplied is voluntary or where we do need consent this is identified. The information provided will be kept in paper form and used for the purpose of maintaining appropriate contact details and for the safety and well-being of your child. Basic DetailsI would like to enrol at the following setting *IverHillingdonHayesChild's Name *Known As *Date of birth *Gender *Name of parent(s) with whom the child lives:Parent Name *Do you have parental responsibillity for this child? *YesNoIf no, do you have legal contact?YesNoParent NameDo you have parental responsibillity for this child?YesNoIf no, do you have legal contact?YesNoAddress of the parent(s) with whom the child lives *CountryUnited States (US)United Kingdom (UK)CanadaAustralia---AfghanistanÅland IslandsAlbaniaAlgeriaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAmerican SamoaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelauBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongo (Brazzaville)Congo (Kinshasa)Cook IslandsCosta RicaCroatiaCubaCuraÇaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqRepublic of IrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalQatarReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Martin (Dutch part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSan MarinoSão Tomé and PríncipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaWestern SamoaYemenZambiaZimbabweCityStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces (AA)Armed Forces (AE)Armed Forces (AP)American SamoaGuamNorthern Mariana IslandsPuerto RicoUS Minor Outlying IslandsUS Virgin IslandsZip codeHome Telephone Number *Mobile Telephone Number - Parent *Mobile Telephone Number - ParentEmail address *Would you prefer to receive newsletters and information via email? *YesNoIf YES please sign here to consent to us contacting you for the purposes aboveReset SignatureName of parent(s) with whom the child DOES NOT liveDoes this parent have parental responsibillity?YesNoDoes this parent have legal contact?YesNoDoes this parent have legal access to the child?YesNoAddressHome Telephone NumberMobile Telephone Number Emergency ContactsEmergency Contact DetailsPlease provide the names and contact details of 2 people (other than parents/guardians) who we can contact in case of an emergency. NOTE: It is your responsibility to ensure these people are happy for us to contact them and to hold their detailsEmergency contact 1Name *Relationship to Child *Home telephone no.Mobile telephone no.Emergency contact 2Name *Relationship to child *Home telephone no.Mobile telephone no. Security DetailsA password system operates in our setting. A secure password is required and should be used by emergency contacts and persons authorised to collect your child. Ideally this should be one word and something that is easily memorable. Please do not use obvious things such as middle names. The password is required from anyone collecting your child. If they do not have the password we will not release your child to them.My secure password is *Authorised Person 1NameRelationship to childHome telephone no.Mobile telephone no.Authorised Person 2NameRelationship to childHome telephone no.Mobile telephone no.Additional security information We have the safety and well-being of the children in mind at all times and we are sure that you will appreciate that persons known to you are strangers to us and we do need means of identifying those you have authorised to collect your child (either authorised or emergency contacts) when you are unable to. We as a setting and especially your child’s key person will be familiar with you but we do not always have the opportunity to meet both parents. This is also true of your nominated emergency contacts and authorised persons. We therefore request that should anyone unknown to us be collecting your child that you inform us in advance and if possible show us a photograph to enable us to identify them when they collect your child. Health InformationHealth InformationDoes your child suffer from any of the following (please select those which apply)AsthmaHeart ConditionDiabetesSight ImpairmentWears GlassesEpilepsyKidney/Bladder ProblemsBee Sting AllergyDeafnessOtherIf you have selected any of the boxes above please give details hereDoes your child require medication, either long term for existing conditions or life saving drugs such as Ventolin? (Please give details of the medication and dosage)Does your child have any special dietary needs or preferences? *YesNoIf yes please give detailsDoes your child have known allergies? *YesNoIf yes please give detailsName of GP *Surgery *Address *CountryUnited States (US)United Kingdom (UK)CanadaAustralia---AfghanistanÅland IslandsAlbaniaAlgeriaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAmerican SamoaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelauBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongo (Brazzaville)Congo (Kinshasa)Cook IslandsCosta RicaCroatiaCubaCuraÇaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqRepublic of IrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalQatarReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Martin (Dutch part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSan MarinoSão Tomé and PríncipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaWestern SamoaYemenZambiaZimbabweCityZip codeTelephone Number * SafeguardingSafeguarding ChildrenDoes your family have a social worker for any reason? *YesNoNameTelephone NumberBased atWhat is the reason for the involvement of Social Services with your family?FOR OFFICE USE – NB If the child has a child protection plan, make a note here, but do not include details. Ensure these are obtained from the social worker named above and keep these securely in the child’s named Child Protection file. Health VisitorThe following information is voluntary and you do not have to complete it. However, we have a legitimate interest in requesting this data as it will assist in providing the necessary care for your child and to allow us to monitor and assess their development.NameTelephone NumberBased atHas your child has their two year progress check?YesNoIf so, on what date was this completed?Are you able to share this information with the setting?YesNo Personal InformationThe following section requires information classed as ‘sensitive personal data’ for which we need your consent to collect and process. We request this data as, in some cases we have a contractual obligation to do so with our Local Authority, but also as we have a legitimate interest to allow us to plan and meet your child’s needs. Ethnicity and Cultural backgroundHow would you describe your child’s ethnicity/cultural background?What is the main religion of your family?Are there any festivals or special occasions celebrated in your culture that your child will be taking part in and that you would like to see acknowledged and celebrated while s/he is in our setting?What is/are the main language(s) spoken at home?If English is an additional language, will this be your child’s first experience of being in an English-speaking environment?YesNo Special Educational Needs and DisabilitiesDoes your child have any special needs or disabilities? *YesNoIf yes please give details belowWhat (if any) special support will your child require in our setting? Professionals involved with the childProfessional 1NameAgencyRoleTelephone NumberProfessional 2NameAgencyRoleTelephone Number Permission & ConsentThe following section contains information for which we need your consent. As required by data protection we have a duty to inform you that you can withdraw your consent for any of the permissions detailed below at any time. Should you wish to withdraw consent please discuss this with a member of staff in the first instance. Permission and ConsentPlease tick the statements below if you consent to the following:I consent to my child participating in off-site outings as part of daily practice e.g. trips to the park, shops, etcI give permission for Lilliput Pre-School staff to apply sun cream to my childI give permission for Lilliput Pre-School staff to put a hypoallergenic plaster onto a minor wound if necessary to keep a wound cleanI give permission for Lilliput Pre-School to act in the best interests of my child in the event of an medical emergencyI consent to my child having their photograph taken for use in displays within the settingI consent to my child’s photograph being used on the settings private social media siteI consent to my child’s artwork (with their name) being displayed in the settingI consent to my child being videoed for use by the setting staff only with regards to observational purposes either assessment of children, an activity or for monitoring children’s behaviourI consent to the video, as mentioned above, to be shared with other professionals visiting the group such as Early Years Advisors, SENCO, Health Visitor etc if necessaryI consent to my child’s learning journey being shared with Ofsted inspectors and/or as part of audits by the local authorityI give consent for Lilliput Pre-School to use my email address to add as a user on Tapestry to view my child’s learning journalI understand that there are photographs of my child in support of their learning and development that will be stored on TapestryI wish to enrol my child (name) *at Lilliput Pre-School starting from (date) *I understand that Lilliput Pre-School uses Tapestry to track children’s learning and development. I understand that staff will share EYFS profile data with the local authority. I understand that staff will raise safeguarding concerns with the Local Safeguarding Children Board. I understand that staff might decide to do this without my knowledge if they were sufficiently concerned about my child.Please sign below to confirm your consent for the indicated statements aboveSignatureReset SignatureDate *Name of signatory *Name of child *Further information regarding how we use children’s images within the setting can be found in our Image Use Policy. Agreement & DeclarationAgreementI agree that if a place is no longer required for my child at Lilliput Pre-School, I am required to give 2 weeks paid notice. I am also aware that my child’s account balance must also be settled prior to leaving. I agree that my child’s fees are payable regardless of any absences due to sickness or holiday which they may take. I agree to ensure that my child’s fees are paid in advance at Lilliput Pre-School (Fees are due on the first day of the week which your child attends and can be paid weekly or monthly in advance)Signature of parent/guardianReset SignatureDate *Name of signatory * DeclarationI declare the information on this form to be correct to the best of my knowledge.Signature of parent/guardianReset SignatureDate *Name of signatory *Person with Parental ResponsibilitySubmit
