Child's Name (in full): *

Name to be Called: *

Address: *

Date of Birth *

Mum's Home Number: *

Mum's Mobile Number: *

Mum's Work Number:

Dad's Home Number: *

Dad's Mobile Number: *

Dad's Work Number:

Name of Child's Doctor: *

Doctor's Address: *

Doctor's Number (Practice): *

Doctor's Number (Mobile):

I consent to any emergency medical treatment necessary during their time at nursery. I authorise the nursery staff to sign any written form of consent required by the hospital authorities if the delay in getting my signature is considered by the doctor to endanger my child's health and safety.

Yes

No

Signed (Insert Full Name): *

Date: *

I agree to abide by all the terms and conditions given to me whilst my child attends Tiny Tots Day Nursery.

Signed (Insert Full Name): *

Date: *