Little Reddings Primary School
Headteacher: Miss Carly Simmonds

‘Learning together, Respecting each other, Success for all’

Harcourt Road, Bushey

Hertfordshire, WD23 3PR
www.littlereddings.org.uk
admin@littlereddings.herts.sch.uk
Tel: 020 8950 5388
Fax: 020 8420 5485

Nursery Admissions

SCHOOL OFFICE USE ONLY
Date Application Received
Date Acknowledged
Birth Certificate
Proof of Address
Details of Placement:

NURSERY APPLICATION FORM

Key Information

Child’s First Name	Click here to enter text.
Child’s Surname	Click here to enter text.
Known As	Click here to enter text.
Child’s Permanent Home Address (at the time of application)	Click here to enter text.
Date of Birth	Click here to enter a date.
Gender	Male ☐	Female ☐
NHS Number	Click here to enter text.
Religion	Click here to enter text.	Ethnicity	Click here to enter text.
Country of birth	Click here to enter text.	First Language	Click here to enter text.
Other Spoken Language(s)	Click here to enter text.
Sibling(s) attending Little Reddings Primary School (please enter their name)	Click here to enter text.
Children Looked After If your child is looked after, or was previously looked after and is now adopted, or with a child arrangements of special guardianship order?	Yes ☐	No ☐
If yes, please provide more details	Click here to enter text.
SEN Does your child have a Statement of Special Educational Needs or an Education Health and Care Plan (EHCP)	Yes ☐	No ☐
If yes, please provide more details	Click here to enter text.
Social or Medical Does your child have a particular medical or social need to go to this school?	Yes ☐	No ☐
If yes, please provide more details	Click here to enter text.
Forces Family	Yes ☐	No ☐
If yes, please provide more details	Click here to enter text.

Parent/Carer 1	Relationship to the child	Click here to enter text.
Parental Responsibility	Yes☐	No ☐
Name	Click here to enter text.
Date of Birth	Click here to enter a date.
National Insurance Number	Click here to enter text.
Address	Click here to enter text.
Click here to enter text.
Post Code	Click here to enter text.
Email Address	Click here to enter text.
Telephone Number	Home	Click here to enter text.	Mobile	Click here to enter text.
Place of Work	Click here to enter text.
Address	Click here to enter text.
Click here to enter text.	Click here to enter text.
Telephone Number	Click here to enter text.	Ext.	Click here to enter text.
Able to Collect Child	Yes☐	No ☐

Parent/Carer 2	Relationship to the child	Click here to enter text.
Parental Responsibility	Yes☐	No ☐
Name	Click here to enter text.
Date of Birth	Click here to enter a date.
National Insurance Number	Click here to enter text.
Address	Click here to enter text.
Click here to enter text.
Click here to enter text.	Post Code	Click here to enter text.
Email Address	Click here to enter text.
Telephone Number	Home	Click here to enter text.	Mobile	Click here to enter text.
Place of Work	Click here to enter text.
Address	Click here to enter text.
Click here to enter text.
Telephone Number	Click here to enter text.	Ext.	Click here to enter text.
Able to Collect Child	Yes☐	No ☐

Do any other individuals have Legal contract arrangement with the child?	Yes☐	No ☐
If Yes, please provide details below and a copy of relevant documentation: Click here to enter text.

Emergency Contacts Other Than Parents/Carers

Contact No. 1	Contact No. 2
Name	Click here to enter text.	Click here to enter text.
Relationship To Child	Click here to enter text.	Click here to enter text.
Address	Click here to enter text.	Click here to enter text.
Telephone No.	Click here to enter text.	Click here to enter text.
Mobile No.	Click here to enter text.	Click here to enter text.

Medical Details

Doctors Name:	Click here to enter text.
Address:	Click here to enter text.
Telephone No.	Click here to enter text.
Health Visitor Name	Click here to enter text.
Address	Click here to enter text.
Telephone No.	Click here to enter text.
Please list any Medical conditions or allergies. Please use a separate sheet if necessary: Click here to enter text.
Does your child have special dietary requirements, due to religious beliefs or allergies (does not include any likes or dislikes): Click here to enter text.

Immunisations – Please Tick If Your Child Has Been Vaccinated Against The Following:

Yes	No	Yes	No
Diphtheria	☐	☐	Tetanus	☐	☐
Hib	☐	☐	Mumps	☐	☐
Measles	☐	☐	Rubella	☐	☐
Polio	☐	☐	Whooping Cough	☐	☐
Details of Other Vaccinations	Click here to enter text.

Previous School/Setting

School/Setting Name	Click here to enter text.
From:	Click here to enter a date.	To:	Click here to enter a date.
Address	Click here to enter text.
Telephone No.	Click here to enter text.

Consents

Medical Treatment
I hearby give consent for the Staff of Little Reddings Primary School to:
Administer Emergency First Aid	Yes ☐	No ☐
Seek Emergency medical and dental attention including hospital treatment if it is deemed necessary	Yes ☐	No ☐
Signature ………Click here to enter text.……………………………………………….	Date ……Click here to enter a date.………………………
Outings
I hearby give consent for the Staff of Little Reddings Primary School to:
To take my child on local visits and outings	Yes ☐	No ☐
Signature ………………Click here to enter text.………………………………………………………….	Date …Click here to enter a date.…………………………………
Photographs/Videos
I hearby give consent for the Staff of Little Reddings Primary School to:
Photograph my child and for those photographs to be used in my child’s file and displays around the school	Yes ☐	No ☐
Use my child’s photographs for School’s website and publicity	Yes ☐	No ☐
Signature ………………Click here to enter text.………………………………………………………….	Date …Click here to enter a date.…………………………………
Sharing Information
I hearby give consent for the Staff of Little Reddings Primary School to:
Share information about my child with other agencies such as: Speech and Language, Health Visitors, Special Education Need Support	Yes ☐	No ☐
Signature ………………Click here to enter text.………………………………………………………….	Date …Click here to enter a date.…………………………………
Please note staff will share information without consent if they are concerned about the welfare of the child

Request for Additional Hours (including 30 Hours free childcare funding)

I am interested in Nursery Lunch Club	Yes ☐	No ☐
I am eligible for 30 hours free childcare funding To check if you are eligible please go to www.childcarechoices.gov.uk	Yes ☐	No ☐
I am not eligible for 30 hours but interested in self-funding additional hours	Yes ☐	No ☐

DECLARATION

The information I have given on this form is complete and accurate. I understand that my personal information will be held securely.

I agree to Little Reddings Primary School using this information to consider my application for a Nursery place. I understand that if any part of this completed application form is found false the offer of a place will be withdrawn.

I understand that the completion of an application form does not guarantee a place in the Nursery class.

I understand that, if offered a place in the Nursery class, I will have to apply separate for a place in Reception.

Please Note

How the information on this form will be used:

By completing this form and signing the declaration you are agreeing for Little Reddings Primary School if they are oversubscribed, to check whether your child’s details meet the school’s published admission rules and if he/she can be offered a nursery place.

Any personal data collected will be treated as confidential under the principles of the Data Protection Act 1998. We will not use the data for any other purpose, nor will we share your data with any third parties other than the Department for Education (for statutory reporting), Hertfordshire County Council departments who may from time to time send you advice, guidance and information relating to chances to early years provision and educational services that are relevant and/or of benefit to your child, and your local child’s centre who support the local authority by assisting families to access the services that child are entitled to.

Thank you for completing our Nursery Application Form.
Please return to the School Office by:
Friday, 23rd March 2018

Name of Person Signing: …………………………………………………………………………………………………

Signature: …………………………………………………………….. Date: Click here to enter a date.…………