Alonim Registration Form - shaarei-tsedek

CHILD’S DETAILS

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

First Name

Surname

Name known as

Date of birth

Gender

Home address

Birth Certificate seen and copy made

Yes
No

FAMILY DETAILS

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

First name

Surname

Relationship to child

Home address

Daytime / Work phone

Home phone

Mobile

Email

Work address

Date of birth

NI Number

Does this parent / carer have parental responsibility for the child

Yes
No

First name

Surname

Relationship to child

Home address

Daytime / Work phone

Home phone

Mobile

Email

Work address

Date of birth

NI Number

Does this parent / carer have parental responsibility for the child

Yes
No

Name

Address

Contact telephone numbers

Relationship to child

What are the contact arrangements that [we/I] need to be aware of?

Name

Address

Relationship to child

Daytime / work phone

Home phone

Mobile

Name

Address

Relationship to child

Daytime / work phone

Home phone

Mobile

Name (Person 2)

Address (Person 2)

Relationship to child (Person 2)

Daytime / work phone (Person 2)

Home phone (Person 2)

Mobile (Person 2)

Password for the collection of child by authorised person:

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

Immunisations

Two months old

5-in-1 (DTaP/IPV/Hib) vaccine - diphtheria, tetanus, pertussis (whooping cough), polio and Haemophilus influenzae type b (Hib).

Yes
No

Date

Pneumococcal (PCV) vaccine.

Yes
No

Date

Rotavirus vaccine.

Yes
No

Date

Three months old

5-in-1 (DTaP/IPV/Hib) vaccine, second dose - diphtheria, tetanus, pertussis (whooping cough), polio and Haemophilus influenzae type b (Hib).

Yes
No

Date

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, tetanus, pertussis (whooping cough), polio and Haemophilus influenzae type b (Hib).

Yes
No

Date

Pneumococcal (PCV) vaccine, second dose.

Yes
No

Date

Between 12 and 13 months old

Hib/Men C booster - Haemophilus influenza type b (Hib), forth dose and meningitis C, second dose.

Yes
No

Date

MMR vaccine – mumps, measles, and rubella.

Yes
No

Date

Pneumococcal (PCV) vaccine, third dose.

Yes
No

Date

Two to three years

Flu vaccine

Yes
No

Date

Three years and four months or soon after

MMR vaccine, second dose – mumps, measles, and rubella.

Yes
No

Date

4-in-1 (DTaP/IPV) pre-school booster - diphtheria, tetanus, pertussis (whooping cough) and polio.

Yes
No

Date

For office use:

Yes
No

Have child’s Health Record Book been seen to confirm immunisation dates?

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

Developmental Information

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's as mentioned above.

What are your child’s dietary requirements?

[please refer to our Food & Drink Policy]

If your child is aged three years or over, does he or she have difficulty with any of the following. (Please tick where applicable)

Does your child have any special needs or disabilities? If so, please specify:

Are any of the following in place for the child?

SEND Action Plan
Education, Health and Care Plan
What special support will he/she require at Alonim Kindergarten?

Please tick if applicable

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

Insert For Office completion

Date of Progress Check	Date seen

As per the requirements of the Early Years Foundation Stage, Alonim Kindergarten will complete a progress check on your child between the ages of 24-36 months. Alonim Kindergarten 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 at Alonim Kindergarten?

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

Yes
No

If English is not the main language spoken at home, will this be your 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 Alonim Kindergarten can work together to support your child when settling in.

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

If Other, please state

General Information

What is your child’s usual sleep pattern? Please tick if 'Yes'

Does your child have any food preferences?
Does your child have a pacifier i.e., dummy or thumb?
Does your child have a special toy or object they might bring with them?

What sort of things does your child enjoy doing at home, i.e., drawing or cooking?

What other information is important for Alonim Kindergarten to know about your child? For example, their likes and dislikes and any fears or any special words they use.

Doctor

Medical Practitioners Contact Information Name Address Telephone

Health Visitor (if applicable)

Name Address Telephone

Social Care Worker (if applicable)
NB if the child has a child protection plan, make a note here, but do not include details. Alonim Kindergarten will ensure these details are obtained from the social care worker named above and keep these securely in the child’s file.

Name (Social Care Worker)

Address (Social Care Worker)

Telephone (Social Care Worker)

What are the reasons for the involvement of the social care department with your family? (Social Care Worker)

Dentist (if applicable)

Name Address Telephone

Any other professional who has regular contact with the child

Name 2

Agency Address Telephone

Name 3

Agency Address Telephone

Name

Agency Address Telephone

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.

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.

Name	Signed	Date	Print

For inhalers/auto-injectors (e.g., EpiPens) only
I give permission for a member of staff who has been appropriately trained to administer the inhaler / EpiPen or Anapen (supplied by me) to (Name of child).

SIGNED	PRINTED NAME	DATE

Nappy Cream
I give permission for nappy cream (supplied by me) to be administered to ……………. (Name of child) when necessary – in accordance with manufacturer’s instructions – and for staff to record its use.

SIGNED	PRINTED NAME	DATE

Paracetamol-based medicine (e.g., Calpol or Sudafed)
I give permission for Alonim Kindergarten 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 planning for my child to be collected as soon as possible in accordance with Managing Children who are sick, infectious or with allergies Policy

NAME OF CHILD	SIGNED	PRINTED NAME	DATE

For Sun Cream
I give permission for nappy cream (supplied by me) to be administered to ……………. (Name of child) when necessary – in accordance with manufacturer’s instructions – and for staff to record its use.

NAME OF CHILD	SIGNED	PRINTED NAME	DATE

Short-Trip / General Outings
Your child will be taken out of Alonim Kindergarten as part of their daily activities. You will be informed of these venues with details nearer the time. They may include: An environment walk in the local area, visit to the church grounds, visit to the neighbouring schools including All Saints’ Primary School and a walk to the local post box. I give permission for ……………………………….. (Name of child) to take part in short trip or 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.

NAME OF CHILD	SIGNED	PRINTED NAME	DATE

Photographs

I / We GRANT permission for filming of my child/children and a photo/image that includes my child / children without any other personal identifiers to be published on the nursery website, newsletter, bulletin, Facebook page, or other social media outlets and publications.
I / We DO NOT GRANT permission for filming of my child/children and a photo/image and that includes my child / children without any other personal identifiers to be published on the nursery website, newsletter, bulletin, Facebook page, or other social media outlets and publications.

As part of the on-going recording of our curriculum and for children’s individual development records, Alonim Kindergarten regularly take photographs of the children during their play. Only iPads supplied by Alonim Kindergarten are used for this purpose, photographs taken are used for display and for your child’s records within Alonim Kindergarten. Alonim Kindergarten may also record events and activities on video. Photos / videos are stored on the Alonim Kindergarten’s computer and iPads only; Alonim Kindergarten only stores images during the period your child is with Alonim Kindergarten. Alonim Kindergarten shares your children’s activities and achievements on our website and social media by filming your child/children and taking images/photos of them without any other personal identifiers. Please tick one of the following choices to either give consent or not give consent.

Publicity
If Alonim Kindergarten would like to use any image of your child for training, publicity, or marketing purposes, Alonim Kindergarten will always seek your written consent for each image we intend to use. I give permission for ……………………………………… (name of child) to have his/her photo taken, or to be videoed, as per the above conditions.

NAME OF PARENT/GUARDIAN	NAME OF CHILD	NAME	NAME 2	NAME 3	SIGNED	PRINTED NAME	DATE

Animals
Alonim Kindergarten may occasionally have a visit from a farm with a variety of farm animals. The nursey has the following pets on site (please list all): A pet hamster called Charlie. Occasionally we may have a visit from a dog. Alonim Kindergarten will ensure that our pets are healthy and fully inoculated, as appropriate, and that animals showing any signs of disease are treated. 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.

NAME OF CHILD	SIGNED	PRINTED NAME	DATE

Policies and Procedures
I have read and understand Alonim Kindergarten’s Policies and Procedures, including the Information Sharing Policy, and understand that there may be circumstances where information is shared with other professionals or agencies without my consent. Signed Printed name Date

Information Sharing Policy
Food and Drink Policy
Making A Complaint Policy
Privacy Notice
Managing Children who are sick, infectious or with allergies Policy
Confidentiality and Client Access to Records Policy

NAME OF PARENT/GUARDIAN	NAME OF CHILD	SIGNED	PRINTED NAME	DATE

Booking Form

When completing this form please confirm the number of sessions you wish to book for your child

CHILD’S FIRST NAME (S)

SURNAME

MORNING SESSIONS:

9.30 am—12.30 pm We recommend a minimum of three Morning Sessions

BREAKFAST CLUB

8.00 am—9.30 am

AFTERNOON SESSIONS

12.30 pm—3.00 pm

Breakfast and Lunch Club fees are charged as incurred and payment collected by Direct Debit

ELIGIBLE CHILDCARE HOURS PER WEEK

Please accept my booking as indicated above.

ACCEPT
I understand and accept the Terms & Conditions and Payment Arrangements as provided to me.
I can confirm that I have completed a Direct Debit Mandate
I can confirm that I have completed the Gift Aid Declaration Form

SIGNATURE OF PARENT / CARER	PLEASE PRINT NAME	DATE

Payment Information

Please make cheques payable to: Sha’arei Tsedek North London Reform Synagogue Please ensure that your form is completed and submitted before the term begins. Childcare Vouchers will be accepted if the Payment schedule is submitted at the beginning of the term. BACS Details Barclays Bank Plc, Wood Green, Leicestershire, LE87 2BB A/C No: 00976369 A/C Name: Sha’arei Tsedek North London Sort Code: 20-98-21 Ref: Alonim Kindergarten + Account No. All acknowledgements and advice notes should be sent to alonim@shaarei-tsedek.org.uk

Gift Aid

Donating through Gift Aid means Alonim can claim an extra 25p for every £1 of the voluntary contributions you give to Alonim. It will not cost you any extra. You can check if you are eligible for Gift Aid here. Please then follow this link to complete the declaration form.

Alonim Kindergarten Terms and Conditions

Click to read our Terms & Conditions The document and the terms and conditions within it govern the basis on which Alonim Kindergarten (referred to here as ‘we’) agree to provide childcare services to parent(s) / carers(s) (referred to here as ‘you’). Only a parent / carer with parental responsibility for a child can register that child for a childcare place with us. We will ask to see your child’s birth certificate, or other relevant documentation, to confirm that you have parental responsibility for the child as part of [our/my] registration process.
Commencement date of agreement:
Expiry date of agreement:
Review date:

Our details: Alonim Kindergarten Charity No. 1171418 Company Registration No. 10514105 Address: 120 Oakleigh Road North, London N20 9EZ Telephone: 020 3115 1610 Email: alonim@shaarei-tsedek.org.uk Ofsted URN: EY557011 Insured by: CONVEX INSURANCE UK LTD Insurance policy number: 21CLM515679

Your details:

Full name of parent/guardian (1)

Address

Telephone

Email

Full name of parent/guardian (2)

Address

Telephone

Email

Full name of child

Date of birth

Agreed hours:

Monday	Tuesday	Wednesday	Thursday	Friday

For Office Use Only

Deposit received

Yes
No

First payment due

Will the child receive nursery education funding

Yes
No

Details of any other funding provided by other third parties (e.g., employers childcare vouchers)

A copy of this completed and signed contract will be provided to each signatory.

Parent Name 1	Signed	Date

A copy of this completed and signed contract will be provided to each signatory.

Parent Name 2	Signed	Date

Relationship to the child

Home address:

Daytime/work telephone

Mobile

Email

Signed on behalf of Alonim Kindergarten

Name	Signed	Date	Position (owner, director, or trustee)

I agree to the Terms of Service