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Complete the form below and we’ll be in touch with you.

Child's Forename

Child's Surname

Name known as

Address

Postcode

Child's Date of Birth

Ethnicity

Venue

Parents/carer's name

Daytime contact no

Emergency contact details

(They must be over 18 and be able to be contacted during playgroup hours.)

Contact One

Name

Address

Telephone number

Relationship to the child

Contact Two

Name

Address

Telephone number

Relationship to the child

Your child will only be able to leave our playgroup with those named above unless agreed in advance of collection.

Health information

Your child will only be able to leave our playgroup with those named above unless agreed in advance of collection.

Address

Postcode

Telephone number

Child's health visitor

Was your child born prematurely?

If yes by how many weeks

Child's Dentist

Address

Postcode

Telephone number

Any allergies, illnesses or current medication?

Does your child have any dietary requirements?

Other information

What language do you speak at home?

Is there anything else you would like to tell us about your child?

Consent

I give consent for my child to be taken to the doctor/hospital by a member of staff and to receive medical treatment if, in the opinion of a doctor/surgeon, a delay is likely to endanger my child's health or safety.

Signed

Date

I give consent for my child to have their photo taken for displays in the playgroup or to be used on our private Facebook page.

Signed

Date

I have read and agree to the Privacy Policy.