Enrolment; Day Nursery

Ashdon House of Children

Baby Care Unit and Day Nursery

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"ASHDON HOUSE OF CHILDREN"
Day Nursery Enrolment Form

Please print this form off in its entirety, complete and post/deliver to the Nursery at the address shown in this form. 

Name of Child _________________________________________

Date of Birth _________________ Age of Child ____Yrs ____Mth

Address _____________________________________________

_____________________________________ Postcode _______
Telephone Numbers:
Home __________________ Work __________________(Mother)
Home___________________Work __________________ (Father)

Mobiles/FAX/E-mail (if applicable) _________________________

Names of Parents/Guardians________________________________
                                        _________________________________
Emergency Contact: (Please provide the name, address & tel no of a relative/friend)  _____________________________________
_____________________________________
_____________________________________
Tel No: __________________________

Doctor's Name _______________________Tel No:_________

Please provide us with the names of those people authorised to collect your child:  _________________________________________

_________________________________________

I do/do not (please delete) give my consent for my child to go on nature walks, farm visits and outings. 
I do/do not (please delete) give my consent for my child to have emergency medical treatment.

SESSIONS REQUESTED

Full Day 8am to 6pm  M  T TH  F  Please circle where applicable
Morning  8am to 1pm M   T TH  F
Afternoon 1pm to 6pm M   T TH  F

Preferred start date for admission to the Nursery : _____________________

Is your child allergic to any food or medication? ______________________________________
______________________________________
Has your child had any serious illness? Is so, what? ______________________________________
______________________________________

IMMUNISATION SCHEDULE
Has you child had the following immunisations ?

At 2 months  HiB  Yes / No
 Diphtheria/Whooping Cough/Tetanus (DTP)  Yes / No
 Polio  Yes / No
At 3 months  HiB Yes / No
 Diphtheria/Whooping Cough/Tetanus (DTP) Yes / No
Yes / No
 Polio
At 4 months  HiB Yes / No
 Diphtheria/Whooping Cough/Tetanus (DTP) Yes / No
 Polio Yes / No
At 12-15 months
 Measles/Mumps/Rubella (MMR) Yes / No
At 3-5 years   Diphtheria (Booster) Yes / No
 Tetanus (Booster) Yes / No
 Polio (Booster) Yes / No

If there is any other information that is relevant to your child, that you feel we should be aware of, please add this below.........

 

 

All the above information will be treated in the strictest confidence.

Please send this Enrolment Form, together with a Registration Fee of 30 (cheques made payable to "Ashdon House Ltd.") to: 

ASHDON HOUSE OF CHILDREN, HILL FARM, RADWINTER ROAD, ASHDON, SAFFRON WALDEN, ESSEX, CB10 2ET

I have read and accept your terms and conditions

Signed: __________________________________Parent / Guardian 
Date: ________________

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Last modified: November 21, 2006