Preschool Registration

* indicates required field

Setting Name:*

Child's First Name:*

Child's Last Name:*

Child's Date of Birth*

Child's Gender:*

Boy
Girl
Gender Neutral

Your Child's Medical Conditions (If applicable)

Your Child's Dietary Exemptions / Allergy Information (If applicable)

Your child's ethnic group*

Special educational needs and disability "SEND" information (if applicable)

Primary Parent / Carer Full Name:*

Primary Parent / Carer Relationship to child:*

Primary Parent / Carer Full Address & Post Code:*

Email:*

Primary Parent / Carer Mobile Phone Number:*

Primary Parent / Carer National Insurance Number (Eligibility Checking):*

Primary Parent / Carer Date of Birth (Eligibility Checking):

2nd Parent / Carer Full Name:

2nd Parent / Carer Relationship to child:

2nd Parent / Carer Mobile Phone Number:

Emergency Contact Person's Full Name (Must NOT be primary parent / carer):*

Emergency Contact Person's Relationship to child:*

Emergency Contact Person's Mobile Number:*

I am applying for:*

Sessions Requested*

About my requested preschool childcare:*

Childcare Place Required From:*

Other childcare provider (if applicable)*

Your 15 / 30 Hour Funded Place Reference Number (Claim Code)

Additional Professionals Supporting Your Child / Family*

Not applicable
Social Worker
Paediatric Dr / Nurse
Speech & Language Therapist
Behaviour Therapist
Other professional not listed

Does your family have an existing CASA or CAF in place?*

Additional Information you would like to provide.

I understand that by submitting this form I will NOT automatically be guaranteed a childcare place. However I will be contacted within 7 days to discuss and confirm my childcare requirements.*

Acknowledged