Child Application Form

Name of parent(s)/carer(s) *

Name of person(s) holding parental responsibility *

Home address *

Home telephone number

Mobile telephone number *

Email address *

Work address *

Work telephone number *

Child's name *

Child's date of birth *

Child's gender MaleFemale

Child's ethnic origin *

Child's religion

Child's first language *

Child's additional language(s) (if applicable)

Child's known disabilities (if applicable)

Child's access requirements (if applicable)

Child's known medical condition(s) (if applicable)

Child's injection(s) received (if applicable)

Child's history of illness(es) (if applicable)

Child's doctor's name *

Child's doctors address *

Child's doctors telephone number *

Child's health visitors name *

Child's health visitors address *

Child's health visitors telephone number *

Has your child visited a speech therapist or paediatrician? *YesNoUnknown

If yes, please give details

Does your child have any dietary requirements, religious or cultural beliefs affecting diet?YesNo

If yes, please give details

Toilet requirements

Emergency contact #1: Contact name *

Emergency contact #1: Contact's relationship to child *

Emergency contact #1: Contact telephone number *

Emergency contact #2: Contact name

Emergency contact #2: Contact's relationship to child

Emergency contact #2: Contact telephone number

Emergency contact #3: Contact name

Emergency contact #3: Contact's relationship to child

Emergency contact #3: Contact telephone number

Person authorised to collect child #1: Contact name *

Person authorised to collect child #1: Contact's relationship to child *

Person authorised to collect child #1: Contact telephone number *

Person authorised to collect child #2: Contact name

Person authorised to collect child #2: Contact's relationship to child

Person authorised to collect child #2: Contact telephone number

Person authorised to collect child #3: Contact name

Person authorised to collect child #3: Contact's relationship to child

Person authorised to collect child #3: Contact telephone number

I give my consent to my child receiving any medical treatment which is urgently necessary *YesNo

If you do not give consent or have a religious or cultural belief why, please explain:

I understand that any carer who suspects that a child in his/her care may have been abused or neglected, has a duty to report this to the Social Services Department *

• Yes, I understand

I confirm that the information submitted via this form is accurate and complete. I am happy for this information to be transmitted via email and used in accordance with Beehive's admissions policy which is available upon request *

• Yes, I confirm

Submit