Please may we have the following information for our records:

Child’s full name………………………………………………………………………. Sex   M/F

Address……………………………………………………………………………….……………

Post code………….…………...Email ........................………................…

Mobile phone……………………………………Telephone………..………………

Date of birth……………………Ethnic Origin…………..Birth Cert or passport no................................

Any cultural requirements…………………………………………………………………….....

Parent/carer full name (the child lives with)..……………………………….....…………………...Title……….…

Parent/carer 2 full name (the child lives with)..……………………………………………….....…...Title …………

In the event of an emergency please give the name address and phone no. of a neighbour/friend that we could contact:

Name………………..………………………………….Telephone………………………….….

Address...........................................................................................................................................

Has your child had his/her tetanus immunisation?Yes/No

Name of Doctor…………………………………….............…...Telephone….........…..………………

Does your child suffer from any allergy or disability?Yes/No

If yes, please give details………………………………..............…………………..……………………

I agree that fees charged by St.Gabriel's Playgroup agreed in advance with myself will be paid in full and on time.

I give permission for St. Gabriel's Playgroup to keep records securely on and off the premises, I understand that information may be shared with other authorities without my consent in certain circumstances. 

We recognise that parents have a right to know that information they share will be regarded as confidential as well as be informed about the circumstances, and reasons, when we are obliged to share information. We are obliged to share confidential information without authorisation from the person who provided it or to whom it relates if it is in the public interest. That is when: it is to prevent a crime from being committed or intervene where one may have been, or to prevent harm to a child or adult; or not sharing it could be worse than the outcome of having shared it. The decision should never be made as an individual, but with the back-up of management committee officers. The three critical criteria are: Where there is evidence that the child is suffering, or is at risk of suffering, significant harm. Where there is reasonable cause to believe that a child may be suffering, or at risk of suffering, significant harm. To prevent significant harm arising to children and young people or serious harm to adults,including the prevention, detection and prosecution of serious crime.

Signature……..……………………………..   Date…….………………………….....................

PLEASE COMPLETE AND RETURN THIS FORM TO:              Days and hours preferred

St Gabriel's Playgroup                                                              __________________________________

PO Box 357.                                                                             __________________________________

Billingshurst,                                                                            ___________________________________                    

RH14 4AL