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. FOR OFFICE USE ONLY 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) WHICH NURSERY DO YOU WISH YOUR CHILD TO ATTEND Please list up to 3 choices in priority order, whilst we will try to offer your first choice this cannot be guaranteed. PLEASE RETURN THE COMPLETED FORM TO YOUR FIRST CHOICE NURSERY. *1. 2. 3. 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. CHILD DETAILS *Forename(s) *Known As *Surname *Date of Birth *Gender (M/F) *Address *Postcode Telephone No. PARENTS/CARERS (living with pupil) Person Making Application *Name *Address *Postcode Telephone No. Mobile No. Parent/Carer Mothers Name (if different from above) Address Postcode Telephone No. Mobile No. Fathers Name (if different from above) Address 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 ADDITIONAL CONTACT INFORMATION Name Address Relationship Tel No’s. Daytime Tel: Home Tel: Mobile: Daytime Tel: Home Tel: Mobile: Daytime Tel: Home Tel: Mobile: 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 Sight Hearing Speech/Language Coordination and movement Behaviour Toileting Educational Psychologist Social Worker Other e.g. Speech Therapist, Physiotherapist Child’s Doctor Child’s Health Visitor *Practice Practice Address 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 Traveller 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. Signed Print Name Date NURSERY APPLICATION FORM 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. Parents/Carers Name of Person making Application Complete address only if it is different from the child’s details. Parents/Carer 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 this. 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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