PreSchool Admissions Form

Birchwood Preschool

'A Bright Start to a Brighter Future'
Preschool Admissions Form
For further information or any queries please email preschool@birchwoodnursery.herts.sch.uk
About your Child
Child's Name *

First Name Last Name
Name known by *
Gender *

Male Female
Date of birth *

Day Month Year
Address *

Street Address

Street Address Line 2

City County

Postcode
Home telephone number
Previous setting attended *

Childminder Day Nursery Preschool/playgroup Other None
Name of setting *
Address *

Street Address

Street Address Line 2

City County

Postcode
Attended from: *

Day Month Year
Attended to: *

Day Month Year
Other children in family
Name

First Name Last Name
Date of birth

Day Month Year
School attended
Add 2nd child

Yes No
Name

First Name Last Name
Date of birth

Day Month Year
School attended
Add 3rd child

Yes No
Name

First Name Last Name
Date of birth

Day Month Year
School attended
Parents/Carers/Contacts
Parent/Carer 1
Name *

Title First Name Last Name
Relationship to the Child *
eg Mother/Father/Carer/Stepmother/Father/Social Worker
Parental responsibility *

Yes No
Date of birth *

Day Month Year
National Insurance Number *
Address *

Street Address

Street Address Line 2

City County

Postcode
Email address *
Mobile number *
Work number
Employer/Location of work
Is there another parent who has parental responsibility? *

Yes No
Parent/Carer 2
Name *

Title First Name Last Name
Relationship to the Child *
eg Mother/Father/Carer/Stepmother/Father/Social Worker
Parental responsibility *

Yes No
Date of birth *

Day Month Year
National Insurance Number *
Address *

Street Address

Street Address Line 2

City County

Postcode
Email address *
Mobile number *
Work number
Employer/Location of Work
In the event that we are unable to contact you, please provide in priority order the names of additional local people we can contact in an emergency:
Contact name 1 *
Contact name 2
Contact name 3
Sessions Required
Please enter required start date: *

Day Month Year

Session times *

	Morning	Afternoon
Monday
Tuesday
Wednesday
Thursday
Friday

Please note that all 30 hours sessions run Monday to Friday inclusive. We do not offer part week or a combination of morning and afternoon sessions due to the manner in which the curriculum is delivered.

30 Hours Entitlement

If both parents/single parents are working more than 16 hours at minimum wage (or equivalent) your child is entitled to 30 hours free child care (including 15 hours education). The free hours will be from 9am – 3pm.

Parents must apply online at www.childcarechoices.gov.uk to obtain an eligibility code before a 30 hour place can be confirmed. Applications can be made as early as 16 weeks before your child’s third birthday.
HMRC code
If you have already applied and obtained your HMRC code, please enter it here
I confirm that I am eligible for the 30 hour offer and will apply at the earliest date possible. I will provide the 30 hour code to Birchwood Preschool once received and understand that any offer of a 30 hour place is conditional upon this requirement. Failure to comply may result in the offer being withdrawn.

Yes
The latest date by which Birchwood Preschool would expect a code to be obtained is 31st May 2021
If you have any other requirements, please enter here
Extended Care

Please specify any additional hours you require above the funded hours you are entitled to. Please note these are subject to availability and are payable monthly in advance.
Additional hours

8.00 - 9.00am (inclusive of breakfast) 3.00 - 4.00pm 4.00 - 5.00pm (inclusive of tea) 5.00 - 6.00pm Holiday club (half terms and holidays)
Medical Information
My child's NHS number *
Doctor's surgery name *
Address *

Street Address

Street Address Line 2

City County

Postcode
Tel no. *
Name of Health Visitor
Does your child have any medical conditions including allergies? *

Yes No
Condition/Allergy *
Treatment *
Details of any medication taken regularly by your child
Comments
In the event of an emergency and you are unable to contact any of the emergency contacts listed above, I give permission for my child to be accompanied by a member of staff and taken to hospital in an ambulance. If necessary I give permission for my child to be X rayed. *

Yes No
Dietary Needs
Does your child have any special dietary needs? *

Yes No
Special dietary needs *

Vegetarian Religious/cultural Medically diagnosed food allergy
Details including date medical diagnosis obtained if relevant *
Please note that parents of children with a food allergy who will be having a school meal with us must complete our catering contractor’s medical questionnaire BEFORE any school meals will be provided. You will be asked to provide medical evidence.
Special Educational Needs & Social Care
Does your child have an Education, Health & Care Plan or an Individual Education Plan? *

Yes No
Is your child or a sibling of your child the subject of an inter-agency child protection plan and has been placed on the Child Protection Register? *

Yes No
Is your child looked after, or has previously been looked after? *

Yes No
Is your child adopted or under special guardianship? *

Yes No
Are there any social or medical concerns? *

Yes No
Are there any other professionals involved with your child? *

Yes No
Details of professionals *
Ethnicity & Culture

Please tick one box below to indicate the ethnic background of your child
White

British Irish Traveller from Irish Heritage Gypsy/Roma Italian Turkish Turkish Cypriot Any other White background
Mixed

White & Black Caribbean White & Black African White & Asian Any other mixed background
Asian or Asian British

Indian Pakistani Bangladeshi Any other Asian background
Black or Black British

Caribbean African Any other Background Chinese Any other ethnic group
I do not wish an ethnic background recorded
First language of child *

English
Religion

Christian Muslim Sikh Buddhist Jew Hindu No Religion
I do not wish to record a religion
Service Child in Education
Has either parent served in the Armed Forces? *

Yes No
Date from *

Day Month Year
Date to *

Day Month Year
Child Collection Password

I give the authority, for any adult (over the age of 16 years) who gives the code word to Birchwood Staff, to hand over my child to his or her care. This code word may be changed at any time. Please ensure you ring to let us know that a different adult is collecting your child.
Password *
Use of Images
While your child is at Birchwood we would like to take photographs or video of them in order to capture their learning and their experiences. These are included on their learning journals which will be available for you to see at Birchwood and electronically. We also sometimes use children’s photographs in displays, literature, staff training, our website and Facebook page and occasionally for the local newspaper. We would like your permission to use photographs or film of your child in this way.

To comply with the Data Protection Act 1998, we need your permission before we can photograph or make any recordings of your child. Please answer the questions below, then sign and date the form where indicated.

I give permission for my child to be photographed and filmed on video for:
My child's learning journal *

Yes No
Within a group photo in the Nursery/Pre-School *

Yes No
Displays of learning and experiences within the Nursery/Pre-School *

Yes No
In the Nursery/Pre-School's publications produced for promotional purposes *

Yes No
On our website *

Yes No
On our Facebook page *

Yes No
An article in the press *

Yes No
Please note that websites can be viewed throughout the world and not just in the United Kingdom where UK law applies.

Conditions of use
- Please contact Birchwood at any time if you wish to withdraw your consent.
- We will not use the personal details or full names (which means first name and surname) of any child or adult in a photographic image on video, on our website, in our documentation or in any of our other printed publications.
- We will not include personal e-mail or postal addresses, or telephone or fax numbers on video, on our website, in our documentation or in other printed publications.
- If we use photographs of individual pupils, we may use the first name of that child in the accompanying text or photo caption within the school or for training purposes, but not in any media publications.
- Photos used within the school for display may be accompanied by the child’s first name, describing what s/he is doing.
- We may use group or class photographs or footage with very general labels, such as “making Christmas decorations”.
Additional Information
I give consent for nappy/clothing to be changed by members of staff *

Yes No
I give consent for nappy cream to be applied when necessary *

Yes No
I give consent for sun cream to be applied when necessary *

Yes No
I give consent for face paint to be applied as required *

Yes No
I give consent for sensitive skin wipes to be used *

Yes No
I am willing for my child to join outings organised by the Class Teacher / Pre-School staff e.g. a short walk, visit to local shops. *

Yes No
Will you require care for your child in the school holidays? *

Yes No Maybe
Data Protection: In accordance with General Data Protection Regulation and current Data Protection Act, the school has a duty to protect this information and to keep it up to date. The school is required to share some of the data with the Local Authority and with the DfE.

Privacy Notice for Parents

In completing this application form you should refer to our Privacy Notice for Parents. The personal information collected on this form will be processed to manage your application in accordance with this policy.
I have read and agree with our Parent Privacy Policy *

Yes
Are you happy for us to share information with your child's next setting?

Yes No
Are you happy for us to receive information from and contact your child's previous setting?

Yes No
I have completed all of the above information asrequested and confirm that the information provided is true and accurate. *

Yes
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Birchwood Preschool

Preschool Admissions Form

About your Child

Parents/Carers/Contacts

Sessions Required

Extended Care

Medical Information

Dietary Needs

Special Educational Needs & Social Care

Ethnicity & Culture

Service Child in Education

Child Collection Password

Use of Images

Additional Information