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Parent/Guardian Name:

Email:

Mobile Number;

Child's Name:

Date of Birth

Centre

Are you a working couple who BOTH work a minimum of 16 hours and are in receipt of working tax credit / Universal credit

Yes

No

Are you a single parent who works a minimum of 16 hours and is in receipt of working tax credit / Universal credit *

Yes

No

House Number/Name

Street

Area

City

Postcode

Alternative Contact Name

Alternative Contact Number

Who will collect the child?

Parent

Guardian

Either

Contact Details of Person Collecting Child

Any medical allergies?

Current School Year

Photo Disclaimer

I DO give permission for photos to be taken during sessions that may contain my child for use in our social media material.

I DO NOT give permission for photos to be taken during sessions that may contain my child for use in our social media material.

Where did you hear about us?