ST WINIFRED’S CATHOLIC PRIMARY SCHOOL – NURSERY
INFORMATION FORM
Please print clearly and complete all boxes
Surname [as shown on birth certificate]: |
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Forenames [as shown on birth certificate]: |
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Usually known as: |
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Date of Birth: |
Gender: |
Nationality: |
Country of Birth: |
Mother’s Surname: |
Forenames: |
Father’s Surname: |
Forenames: |
Home Address: |
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Home Telephone No: |
Email: |
Normal Mode of Travel: |
Resident in London Borough of: |
IN THE EVENT OF ILLNESS/EMERGENCY THE FOLLOWING TELEPHONE NUMBERS WILL BE USED. WE WILL AUTOMATICALLY CONTACT PARENTS FIRST, UNLESS INSTRUCTED OTHERWISE.
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Mother’s Contact Numbers:
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Home: …………………………………………………………….
Mob: …………………………………………………………….
Work: ……………………………………………………………
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Father’s Contact Details:
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Address [if different from above]:
Home: …………………………………………………………..
Mob: …………………………………………………………..
Work: ………………………………………………………….
Email: …………………………………………………………. |
Other Contact Numbers:
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Name: ………………………………….. [Relationship to child: ]
Phone No: ……………………………………
Name: ………………………………… [Relationship to child: ]
Phone No: …………………………………….
Name: ………………………………… [Relationship to child: ]
Phone No: ……………………………………… |
Home Circumstances: |
2 parents ……. 1 parent ……. 1 parent/1 step parent ……. Looked after/Adopted …….
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Family Doctor’s Name & Address:
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Medical Conditions or Allergies [e.g. asthma; allergy to penicillin; nut allergy]: |
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Medication if Necessary: |
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Medication Required in School: |
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Any Other Medical/Dietary Information: |
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Name & Address of Previous Nursery or School:
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Date started ………………………… Date left ……………………………. |
Religion:
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Roman Catholic ¨ Church of England ¨ Christian ¨ Orthodox ¨ Muslim ¨ Hindu ¨ Other [please state] ¨ No Religion ¨ Refused ¨ |
the following information will be used by the local education authority to assess the school for additional funds for teaching purposes | |
Main language spoken at home: |
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Any other language spoken at home: |
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Date of Entry into the UK, if applicable: |
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Date of First Exposure to English, if applicable: |
Signature of Parent/Carer ……………………………………………………………………… Date …………………………………………………………