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NEW ERA NURSERY SCHOOL APPLICATION FORM
Address: ----------------------------------------------------------------------------------------------------------------------------- Date of birth: ------/------/------ Contact Email address: ---------------------- Contact Tel No: -------------------- Father: Name: ----------------------------------------- Mother: Name: ------------------------------------------------ Daytime Telephone:----------------------------------- Daytime Telephone:------------------------------------------- Evening Telephone:------------------------------------- Evening Telephone:-------------------------------------------- Email Address: ------------------------------------------ Email Address: -------------------------------------------------- Address:------------------------------------------------ Address: ---------------------------------------------------------- Who may be contacted in an emergency if parents are not available? Name: --------------------------------------------------------------------------------------------------------------------------------- Address: ------------------------------------------------------------------------------------------------------------------------------ Telephone no: ----------------------------------------------------------------------------------------------------------------------- Relationship to child: -------------------------------------------------------------------------------------------------------------- Family Doctor’s Name: ----------------------------------------------------------------------------------------------------------- Address: ------------------------------------------------------------------------------------------------------------------------------ Telephone No: ---------------------------------------------------------------------------------------------------------------------- Medical History (any illness, disability or allergy suffered by the child): -------------------------------------------- Is special care and attention needed? [] Yes [] No (if yes give details)--------------------------------------------- Food: Special diet, likes/dislikes --------------------------------------------------------------------------------------------- Immunisations (1) Mumps Yes [] No [] Date: -----/-----/----- (2) Measles Yes [] No [] Date: -----/------/----- (3) Polio Yes [] No [] Date: -----/-----/----- (4) Rubella Yes [] No [] Date: -----/------/----- (5) Diphtheria Yes [] No [] Date: -----/-----/----- (6) Tuberculosis Yes [] No [] Date: -----/------/----- (7) Tetanus Yes [] No [] Date: -----/-----/----- (8) Hepatitis Yes [] No [] Date: -----/-----/------ (9) BCG Yes [] No [] Date: -----/----/----- (10) Meningitis C Yes []No [] Date: -----/------/----- (11) Whooping Cough Yes [] No [] Date: -----/-----/----- Anything else we should know about your child? [] Yes [] No (if yes give details) ------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------- I give permission for my child to go on outings with staff. [] Yes [] No I give permission for my child to be photographed in School [] Yes [] No to collect my child in the event of my absence. How did you hear about us? (1) Internet (2) Leaflet (3) Word of mouth (4) Health Board (5) NCNA (6) Leinster Leader (7) Banner (8) Kildare Times (9) Others -------------------------- Are you a friend/relative of the Partners or any Staff of New Era Nursery School Yes [] No [] I agree to the terms and conditions of New Era Nursery School as stated in the brochure (which may be updated from time to time) and that: 1. Under no circumstance is Nursery fee refundable. 2. Booking fee is ONLY refundable if I give at least one month’s notice of child withdrawal latest by the time that I make my last or final Nursery fees payment. 3. I will not withdraw my child from the Nursery and give him/her to a present or former employee of New Era Nursery for childcare service. Doing this will incur an introduction fee of 250 euros and forfeiture of booking deposit.
SIGNED: ---------------------- Relationship to child:------------------------------- Date: ------/--------/------
OFFICIAL USE Friend/Neighbour/Relative of Partners Yes [] No [] Admitted Yes [] No [] Application form checked with parent Yes [] If yes date: -----/-----/----- No [] If no, reason:------------------ Birth Certificate Seen Yes [] No [] If no, reason:-------------- Bilingual Yes [] No [] Languages --------------- Notes on any special care and attention completed. Yes [] No [] and attached [] Home knowledge form Yes [] No [] If yes date: -------/--------/-------- Agreement for medical treatment form completed Yes [] No [] If yes date: -------/-------/-------- Parental consent form for medicines completed. Yes [] No [] If yes, date -------/-------/-------- Partnership form given Yes [] No [] If yes, date -------/-------/------- Partnership form signed and returned Yes [] No [] If yes, date -------/-------/------- Brochure given to ------------------------ Yes [] No [] If yes, date -------/-------/------- Type of booking: Full day [] Mornings only [] Afternoons only [] Variations/Split days [] ---------------- Booking Fee paid: ----- Monthly Nursery Fees: ----- Booking Date: -----/-----/----- Entry date: -----/-----/---- Stationary Fees: --------- Uniform Bought: Bib [] Polo shirt [] Sweatshirt [] Jogging Suit [] Date of leaving service: -----/-----/---- Destination: --------------------- Reason for leaving -------------------
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