Nursery Application Form - PDF by zxb18105


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									                                                                                                   Version 2.0

                                   Nursery Application Form
The information on this form is processed electronically for administrative purposes and is subject to the terms of the Data
Protection Act 1998. Please note that the information requested marked with a * represents mandatory fields which must
be completed before the application can be processed.

Date of Application                                     Proof of address attached              Yes         No
Start Date                                              Birth Certificate attached             Yes         No
Details of Placement                                    Category to be applied (1-7)

Please list up to 3 choices in priority order, whilst we will try to offer your first choice this cannot be

If a place cannot be made available in your first choice of nursery you may wish to attend another nursery
this year but you must advise the Head Teacher of the nursery of your first choice if you wish to remain on
the waiting list.
Please indicate if you wish to split your funding between one or more nursery                   Yes              No

If yes, please provide further details         Centre Name
                                               Number of Sessions Attended

Placement Requested
Please indicate which sessions you wish the child to attend nursery
                    Monday            Tuesday          Wednesday                       Thursday              Friday
AM                                                                                                   
PM                                                                                                   
Full Time                                                                                            
Important - Please note that requests for Full Time placements will be assessed and allocated in line
with the current Early Years Admissions and Review Policy.

*Forename(s)                                                                 *Known As
*Date of Birth                                                               *Gender (M/F)

*Postcode                                                  Telephone No.
PARENTS/CARERS (living with pupil)
Person Making Application


*Postcode                                           Telephone No.
                                                    Mobile No.
Mothers Name
(if different from above)

Postcode                                            Telephone No.
                                                    Mobile No.
Fathers Name
(if different from above)

Postcode                                            Telephone No.
                                                    Mobile No.

Sibling Information
Other Children in the family in order of age with the oldest first. Please note the Child’s Date of Birth
(DOB) is to be recorded in the format (DD/MM/YYYY)
Name                                                               Date of Birth
Name                                                               Date of Birth
Name                                                               Date of Birth

Name         Address                                   Relationship           Tel No’s.
                                                                              Daytime Tel:
                                                                              Home Tel:
                                                                              Daytime Tel:
                                                                              Home Tel:
                                                                              Daytime Tel:
                                                                              Home Tel:
Disability and Medical Information

* Does the child have any long-term illness, medical condition or disability?    Yes        No

If yes, please give a brief description:

If yes, has there been a professional assessment identifying a disability? Yes         No

If yes, can you provide copies of the professional assessments?           Yes          No

I do not wish to disclose this information.

Special Dietary Requirements?                                             Yes          No

If yes, please provide details below

Please provide details of any concerns you may have about your child’s
Coordination and
Social Worker

Other e.g. Speech

Child’s Doctor                                         Child’s Health Visitor
*Practice                                              Practice Address

Post Code                                              Post Code
*Telephone No.                                         Telephone No.

Additional Information to support application (including information relating to
special family circumstances which may determine a priority place)

Previous Pre-Nursery Experience (e.g. Children’s Centre, Playgroup, Nursery)
Ethnic Origin - Please tick the one category.
Asian Bangladeshi                  Black Caribbean                   Other (please specify)         
Asian Chinese                      Black Other                       Not Disclosed                  
Asian Indian                       Gypsy Traveller                   Not Known                      
Asian Other                        Mixed                             White UK                       
Asian Pakistani                    Occupational                      White Other                    
Black African                      Other Traveller            
If you have ticked one of the ‘Other’ boxes for any of the above ethnic origins, please enter the specific
ethnic origin here: -

Main Home Language – Please tick the one category.
 Arabic                French               Italian                          Punjabi               
 Bengali               Gaelic               Norwegian                        Spanish               
 Cantonese             Gujerati             Other (please specify)           Turkish               
 English               Hindi                Polish                           Urdu                  
Additional Home Language(s) - Please List:

Religious Affiliation - Please tick any religious affiliation below
 Buddhist                          Jewish                       Not Known                           
 Christian – Other                 Muslim                       Other (please specify)              
  Christian – RC                   No Religion                  Sikh                                
  Hindu                            Not Disclosed               
If you have ticked the ‘Other’ box please enter the specific religion here:

National Identity - Please tick the one category
 British                           Other (please specify)             Not Known                     
 English                           Northern Irish                     Scottish                      
 Irish                             Not Disclosed                      Welsh                         
If you have ticked the ‘Other’ box please enter the specific National Identity here:

Asylum Status - Please tick the one category.
 Asylum Seeker                     Refugee                            Not Applicable               
I declare the information on this form to be correct to the best of my knowledge.


 Print Name                                                             Date
Completion Advice Note
General Information
You should only complete one nursery application form per child. The application form enables you to list in order of
preference up to 3 local authority nurseries you would like your child to attend. There is no requirement to list more than one
local authority nursery. However, as the first choice cannot be guaranteed it is recommended that you indicate a second and
third choice.
The form when completed should be submitted to the establishment which would be your preferred first choice of nursery. If
more than one application form is submitted the most recent form will be processed and the other forms will be disregarded.
Please take the child’s birth certificate and proof of address to the nursery when you submit the application or send a copy with
the form if you are sending your completed form by post. Please send copies only as they cannot be returned. Enrolment
cannot take place without this information being provided.
Placement Requested
Please put a tick in each of the boxes indicating which nursery sessions you wish your child to attend. No guarantee can be
given but we will try to take account of your preference if a place is available.
Full Time Placement Requests -
Additional free sessions may be available in some nurseries to children and families whose needs fulfil the criteria contained
within the Early Years Admission and Review Policy. The decision to allocate additional sessions will be taken by the Head
of Establishment in conjunction with the Early Years and Childcare Service Manager. Two written assessments are required
from other professionals involved with the family (i.e. Health Visitor, Social Worker, Educational Psychologist, other health
professional, etc) in order to establish whether or not the criteria are met and that the provision of additional sessions is in the
child’s best interests. This decision must be reviewed termly and will not be guaranteed for the whole school session. Where
capacity allows it may be possible to buy additional hours to support your work or continuing training/further education.
Again, these places would be reviewed termly and could not be guaranteed for the whole session.

Name of Person making Application
Complete address only if it is different from the child’s details.
If someone other than the parents makes this request for a nursery place, then parents' details should be completed here. Please
note that under the provisions of Part 1 of the Children Act 1995 it may be necessary for the nursery to keep both parents
advised of progress at nursery and nursery events. Please speak to the head of the establishment if you have any queries about

Additional Contact Information
Please include details of significant others who may also be contacted in the event of an emergency.

Disability and Medical information
We do not need to know about normal childhood ailments the child has had. We are interested in ongoing health problems
requiring continuing treatment. If you have answered YES please provide details. Please provide as much detail as possible
about any additional needs your child may have and any other professionals involved, to ensure that the nursery has a clear
understanding of your child’s needs. It is required that in all cases you provide your Doctor’s contact details.
Additional Information
We have asked a lot of questions to help assess your application. If you feel there is other information which might affect the
outcome of your application please complete this section.
Previous Pre-Nursery Experience
It is helpful to know if your child has had any previous nursery experience in order to request relevant transition information.

Ethnic Background
We have to collect information on ethnic origin. This makes sure that no group is disadvantaged and that we meet the needs of
all the children.

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