KALEIDASCOPE AYLESHAM KALEIDASCOPE DOVER

St Josephs RC Primary School Methodist Church Hall

Ackholt Road Bartholomew Street
Aylesham Dover
Kent CT16 2LH
CT3 3AS
01304 219509
01304 842363
kaleidascope@hotmail.co.uk kaleidascope-dover@hotmail..com

Registration form
Child’s details

Child’s first name(s) Surname

Name known as
Child’s full address

Birth certificate seen Yes □ No □

Gender Date of birth BC number_________________________

Family details

Name of parent(s)/carer(s) with whom the child lives:

Contact details 1 (including emergency information):

Parent/carer full name DOB
Relationship to child
Daytime/work telephone Mobile
Home telephone Email
Home address
Work address

NI Number (for purposes of

free entitlement and 30 free
hours application)

Are you in receipt of any

benefits? Please list
__________________
(for purposes of EYPP,free
entitlement and 30 free hours
application)

Does this parent have parental responsibility for the child? Yes □ No □

Contact details 2 (including emergency information):

Parent/carer full name DOB
Relationship to child
Daytime/work telephone Mobile
Home telephone Email
Home address
Work address
NI Number (for purposes of free entitlement and 30 free hours application) _____________________________________
Are you in receipt of any benefits? Please list____________________________________________________
(for purposes of EYPP,free entitlement and 30 free hours application)

Does this parent have parental responsibility for the child? Yes □ No □

Contact details 3 (including emergency information):

Parent/carer full name DOB
Relationship to child
Daytime/work telephone Mobile
Home telephone Email
Home address
Work address
Does this parent have parental responsibility for the child? Yes □ No □

Other person(s) with legal contact To be completed where those persons with parental responsibility are
separated and an S8 Order is in place.

Name
Address
Contact telephone numbers
Relationship to child
What are the contact arrangements that we need to be aware of?

Emergency contact details if parents are not available Emergency contacts must be local.

Contact 1 - Name
Relationship to child
Address
Daytime/work telephone
Home telephone Mobile

Contact 2 - Name
Relationship to child
Address
Daytime/work telephone
Home telephone Mobile

Persons other than parent(s) authorised to collect the child Must be over 16 years of age. Please note
that if the authorised person is not the person indicated on the daily signing in/out sheet, staff will check before
releasing the child.

Person 1 – Name
Relationship to child
Address
Daytime/work telephone
Home telephone Mobile

Person 2 - Name
Relationship to child
Address
Daytime/work telephone
Home telephone Mobile

Person 3 - Name
Relationship to child
Address
Daytime/work telephone
Home telephone Mobile

Password for the collection of child by authorised persons

About your child

The following information will tell us a little more about your child. As your child settles with us, we will
establish their starting points through observation and further conversation with you.

Does your child have previous experience of attending a childcare setting? If so, please specify:

Health and development

Has your child received the following immunisations? Please confirm and provide date of immunisations given.
Two months old 5-in-1 (DTaP/IPV/Hib) vaccine - diphtheria, tetanus, Yes □ No □ Date:
pertussis (whooping cough), polio and Haemophilus
influenzae type b (Hib).
Pneumococcal (PCV) vaccine. Yes □ No □ Date:

Rotavirus vaccine. Yes □ No □ Date:

Three months old 5-in-1 (DTaP/IPV/Hib) vaccine, second dose - Yes □ No □ Date:
diphtheria, tetanus, pertussis (whooping cough), polio
and Haemophilus influenzae type b (Hib).
Meningitis C vaccine. Yes □ No □ Date:

Rotavirus, second dose. Yes □ No □ Date:

Four months old 5-in-1 (DTaP/IPV/Hib) vaccine, third dose - diphtheria, Yes □ No □ Date:
tetanus, pertussis (whooping cough), polio and
Haemophilus influenzae type b (Hib).

Pneumococcal (PCV) vaccine, second dose. Yes □ No □ Date:

Between 12 and Hib/Men C booster - Haemophilus influenza type b Yes □ No □ Date:

13 months old (Hib), forth dose and meningitis C, second dose.

MMR vaccine – mumps, measles and rubella. Yes □ No □ Date:

Pneumococcal (PCV) vaccine, third dose. Yes □ No □ Date:

Two to three Flu vaccine

Yes □ No □ Date:
years
Three years and MMR vaccine, second dose – mumps, measles and
Yes □ No □ Date:
four months or rubella.
soon after
 4-in-1 (DTaP/IPV) pre-school booster - diphtheria, Yes □ No □ Date:
tetanus, pertussis (whooping cough) and polio.

For internal use: Has the child’s health record book been seen to confirm immunisation dates? Yes □ No □

Does your child have any on-going medical conditions? If so, please specify:

If yes, please specify which external agencies are involved e.g. Paediatrician, Consultant, Dietician, Speech
and Language Therapist, etc:

Does your child require a health care plan? Yes □ No □

Is your child known to have any allergies or food intolerances? If so, please specify:

A risk assessment will be completed and kept on the child’s file for any known allergies or food intolerance as
mentioned above.

What are your child’s dietary requirements? Please specify:

If your child is aged three years or over, does he or she have difficulty with any of the following:
Speaking and communicating Yes □ No □
Listening and attending Yes □ No □
Understanding simple instructions Yes □ No □
Eating and drinking Yes □ No □
Sitting and sharing a book Yes □ No □
Walking and climbing Yes □ No □
Rolling a ball Yes □ No □
Holding a crayon Yes □ No □
Socialising with adults and other children Yes □ No □
Using the toilet Yes □ No □
Putting on their shoes and socks Yes □ No □
Any other concerns:
Does your child have any special needs or disabilities? If so, please specify:

Are any of the following in place for the child?

SEN action plan
Education, Health and Care Plan

What special support will he/she require in [our/my] setting?

Two year old progress check – children aged 24 – 36 months

If your child is aged between 24-36 months, has a two year old progress check already been completed for
your child? Yes □ No □
Setting completing check Date completed

As per the requirements of the Early Years Foundation Stage [we/I] will complete a progress check on your
child between the ages of 24-36 months. [We/I] will ask you to be involved in completing the check and will
discuss it with you.

Cultural background
How would you describe your child's ethnicity or cultural background?

What is the main religion in your family (if applicable)?

Are there any festivals or special occasions celebrated in your culture that your child will be taking part in and
that you would like to see acknowledged and celebrated while he/she is in [our/my] setting?

What language(s) is/are spoken at home?

If English is not the main language spoken at home, will this be your Yes □ No □
child's first experience of being in an English-speaking environment?

Does your child need a bilingual support plan? Yes □ No □

If so, discuss and agree with the key person how [we/I] can work together to support your child when settling-
in:

General information
What is your child’s usual sleep pattern?

Does your child have any food preferences? Yes □ No □

Does your child have a pacifier i.e. dummy or thumb? Yes □ No □
Does your child have a special toy or object they might bring with them? Yes □ No □
What sort of things does your child enjoy doing at home, i.e. drawing or cooking?

What other information is it important for [us/me] to know about your child? For example, what they like, or
what fears they may have, or any special words they use.

Details of professionals involved with your child

GP
Name Telephone
Address

Health Visitor (if applicable)

Name Telephone
Address
Social Care Worker (if applicable)
Name Telephone
Address

What is the reason for the involvement of the social care department with your family? NB If the child has a
child protection plan, make a note here, but do not include details. [We/I] will ensure these details are obtained
from the social care worker named above and keep these securely in the child's file.

Dentist (if applicable)

Name Telephone
Address

Any other professional who has regular contact with the child
Name 1 Role
Agency Telephone
Address

Name 2 Role
Agency Telephone
Address

Name 3 Role
Agency Telephone
Address

General parental permissions

Emergency treatment declaration

In the event of an accident or emergency involving my child I understand that every effort will be made to
contact me immediately. Emergency services will be called as necessary and I understand my child may be
taken to hospital accompanied by the manager or authorised deputy for emergency treatment and that health
professionals are responsible for any decisions on medical treatment in my absence.
Signed Date
Printed name

For inhalers/auto-injectors (e.g. Epipens) only

I give permission for a named member of staff who has been appropriately trained to administer the inhaler/
Epipen or Anapen (supplied (name of child).
by me) to
The named staff are:




Signed Date
Printed name

Nappy cream
I give permission for nappy cream (supplied by me) to be administered to
(name of child) when required, in accordance with manufacturer’s instructions.

Signed Date
Printed name

Paracetemol based medicine (e.g. Calpol or Sudafed)

I give permission for staff to administer paracetamol based products (e.g. Calpol) to
(name of child) in the case of a raised temperature and on the
understanding that I will be making arrangements for my child to be collected as soon as possible in
accordance with the setting’s procedures on the administration of medicines.

Signed Date
Printed name

Suncream
I give permission for [staff/name of childminder] to administer hypoallergenic suncream (supplied by me) to
(name of child) when necessary and to record its use.

Signed Date
Printed name

Short trip - general outings

Your child will be taken out of our setting as part of the daily activities. The venues used are detailed here:
Local parks, walks to shops, library and places of interest in the local area.
I give permission for (name of child) to take part in short trips or
general outings. I understand that individual risk assessments are carried out for each type of trip or outing
taken and are available for me to see as required. For any planned outings, I understand I will be informed and
my specific consent obtained.

Signed Date
Printed name

Photographs
As part of the on-going recording of our curriculum and for children’s individual development records, staff
regularly take photographs of the children during their play. Only cameras supplied by the setting are used for
this purpose, photographs taken are used for display and for your child’s records within the setting..
Photos/videos are stored on the setting’s computer only; we only store images during the period your child is
with us. If we would like to use any image of your child for training, publicity or marketing purposes, we will
always seek your written consent for each image we intend to use.
I give permission for
(name of child) to have her/his photo taken, or to be
videoed, as per the above conditions.

Signed Date
Printed name

Animals
We may occasionally have supervised visits of animals to our setting
. A risk assessment will be carried out for visiting animals, and parents informed.
Please state below any known allergies or aversion (name of child) has to animals:

Signed Date
Printed name

Key persons - Information for parents

Each child joining the setting will have a key person appointed to them. It will be the key person’s responsibility
to ensure that your child receives the best possible attention whilst in our care and to ensure that their records
are kept up-to date. Your child’s key person may change as your child progresses through the setting. You will
be notified of these changes. Your child’s key person is your first point of contact for anything you wish to
discuss about your child.
Your child’s key person will be
Your child’s ‘back up’ person will be

To be completed by the key person/manager:

Date starting at (name of provider)
Days and times of attendance

Are any fees payable? If so, note here

Has the settling-in process been agreed? Yes □ No □
If so, please specify:

Policies and procedures

I have been provided with details of Kaleidascope Childcare Ltd policies and procedures. The policies and
procedures have been explained to me, including the Information Sharing Policy, and I understand that there
may be circumstances where information is shared with other professionals or agencies without my consent.
Signed Date
Printed name

Please sign below to indicate that the information given on this form is accurate and correct, and that you will
notify us of any changes as they arise.

Parent name
Signed Date

Name of key person

Signed Date
Name of manager

Signed Date
Date of first review

Equalities monitoring form

Ethnicity - Gathered for monitoring purposes only. Parents are not obliged to complete this data.

White British □ Pakistani □

White Irish □ Indian □

White other □ Asian other □

Black British □ Chinese □

Black African □ Chinese other □

Black Caribbean □ White and Black Caribbean □

Black Other □ White and Black African □

Bangladeshi □ White and Black Asian □

Other please state
LANGUAGES SPOKEN____________________________________________________________________
A child’s learning difficulties and disabilities status should be recorded according to the following categories:
No special educational need □
SEN action plan □
Education, Health and Care Plan □
Providers should refer to the SEND Code of Practice for the Early Years (2014) for an explanation of the terms
above.