mallards wood daycare

Booking Form

Please print below form, complete and return:

Booking Form

Mallards Wood Daycare
157/159 St Barnabas Road
Woodford Green
Essex IG8 7DG

Mallards Wood Booking Form Page 1 of 4

Childs Full Name ..............................................


Date of Birth ................................................... (or expected date)

Known as ...........................................................

Address ............................................................
  .........................................................................
  .........................................................................

Postcode ...........................................................

Home Telephone Number ................................

Gender .......................

Cultural or Religious observance ................................................

Language used or spoken at home ...............................................

------------------------------------------------------------------------------------------------------------

Mothers Full Name ......................................................................

Address ........................................................................................
If different ................................................................................
from child) ................................................................................

Postcode ......................................................

Home Telephone Number ....................................
Mobile Number .....................................................
Home Email ...........................................................
Job Title ..............................................................

Work Address .....................................................
  ....................................................
Postcode .....................................

Work Telephone Number ..................................
Work Email ........................................................
Work Department ..............................................
Hours of work ....................................................
Days at work .......................................................

Mallards Wood Booking Form Page 2 of 4

Fathers Full Name ..............................................

Address ...............................................................
If different .......................................................
from child) .......................................................
Postcode ..............................................

Home Telephone Number .................................
Mobile Number .................................................
Home Email .......................................................
Job Title ...........................................................
Work Address ..................................................
  .........................................................................
Postcode ..............................................

Work Telephone Number ...............................
Work Email .....................................................
Work Department ...........................................
Hours of work .................................................
Days at work ...................................................

-----------------------------------------------------------------------------------------------

Guardian or Carers Full Name ......................................................................................

Relationship to child .............................................................

Address .................................................................................
If different .........................................................................
from child) .........................................................................
Postcode ..............................................

Home Telephone Number .............................
Mobile Number .............................................
Home Email ...................................................
Work Address ..............................................
  .....................................................................
Postcode ..............................................

Work Telephone Number .......................
Work Email .............................................
Work Department ...................................
Hours of work .........................................
Days at work ...........................................

Mallards Wood Booking Form Page 3 of 4

Third Contact Full Name..............................................

Relationship to child ...................................................

Address ........................................................................
If different ................................................................
from child) ................................................................
Postcode ...........................

Home Telephone Number ............................................
Mobile Number ............................................................
Home Email ..................................................................
Job Title ......................................................................

Work Address .............................................................
  ....................................................................................
Postcode ...........................

Work Telephone Number ..........................................
Work Email ................................................................
Work Department ......................................................
Hours of work ............................................................
Days at work ..............................................................

Medical Details

Childs Doctors Name..............................................

Address ...................................................................
 ................................................................................
Postcode ..............................................

Telephone Number .................................................

Health Visitors Name .............................................

Telephone Number .................................................

Medical History ............................................................................................................

Allergies ........................................................................................................................

Dietary Needs ..............................................................................................................

Immunisation Polio[ ]
...................Tetanus[ ].......................PLEASE TICK
...............Diptheria [ ].......................IF RECIEVED
....Whooping Cough[ ]
........................MMR[ ]
......................B.C.G. [ ]
......................H.I.B. [ ]

Are there any special dietary requirements due to health, religious or cultural reasons
or any other information that would be helpful to the nursery staff.

.................................................................................................................................
.................................................................................................................................
.................................................................................................................................

Mallards Wood Booking Form Page 4 of 4

PARENTAL AGREEMENT

Exact starting date required: ......................................................

  Places required for full days (there is a minimum of two days)

  Monday..[....].......Tuesday..[....]........Wednesday..[....]........Thursday..[....]........Friday..[....]

Places required for morning or afternoon sessions

 It is agreed that full payment will be made into our account by the first of the month

Mallards Wood can only accept cheques for deposit charges, all other fees are payable by standing order.

It is agreed that Mallards Wood will receive one months notice if the childs place is no longer
required otherwise there will be a charge payable of one month fees in lieu of notice,
the nursery has a right to ask a child to leave if it becomes necessary.

It is agreed that my child can be seen and treated by a doctor in case of emergency.

It is agreed that a late collection fee will be paid if the child is collected outside of agreed hours..

It is agreed that the nursery has an obligation to inform the relevant authorities if they feel
that the childs welfare is in danger.

I agree to abide by the nurseries terms and conditions and that all the information given is true
and any changes will be notified to the nursery.

Signed ........................................... Dated .............................. Parent/Guardian (delete as necessary)