Child Application Form Please enable JavaScript in your browser to complete this form.Name of parent(s)/carer(s) *Name of person(s) holding parental responsibility *Home address *Home telephone numberMobile telephone number *Email address *Work address *Work telephone number *Child's name *Child's date of birth *Child's gender MaleFemaleChild's ethnic origin *Child's religionChild'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? *YesNoUnknownIf yes, please give detailsDoes your child have any dietary requirements, religious or cultural beliefs affecting diet?YesNoIf yes, please give detailsToilet requirementsEmergency contact #1: Contact name *Emergency contact #1: Contact's relationship to child *Emergency contact #1: Contact telephone number *Emergency contact #2: Contact nameEmergency contact #2: Contact's relationship to childEmergency contact #2: Contact telephone numberEmergency contact #3: Contact nameEmergency contact #3: Contact's relationship to childEmergency contact #3: Contact telephone numberPerson 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 namePerson authorised to collect child #2: Contact's relationship to childPerson authorised to collect child #2: Contact telephone numberPerson authorised to collect child #3: Contact namePerson authorised to collect child #3: Contact's relationship to childPerson authorised to collect child #3: Contact telephone numberI give my consent to my child receiving any medical treatment which is urgently necessary *YesNoIf 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 understandI 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 confirmSubmit