MERSEY DRIVE - Nursery

Nursery

30 Free Hours deadline

Nursery Application Form

Child's First Names:

Child's Surname:

Legal Surname:

Gender:

Date of Birth

Your child’s permanent address at the time of application including post code:

Special Educational Needs: Does your child have a Statement of Special Educational Needs or an Educational Health & Care Plan? Does your child have any speech or language difficulties? If yes, is evidence enclosed?

At Risk: Is your child or a sibling of your child, subject of an inter-agency? Child protection plan and has been placed on the Child Protection Register? If yes, please provide evidence.

Children in Public Care: Is your child looked after or was previously looked after?

Social or Medical Reasons: A child/family who can demonstrate they have a particular medical or social need to attend the school. Please provide supporting evidence with this form.

Siblings: Does your child have siblings at this school, enter their name/s and date of birth:

Child 1 Name

Child 1 date of birth

Child 2 Name

Child 2 date of birth

Child 3 Name

Child 3 date of birth

Pre-School: Name and address of Early Years setting your child attends or has attended (if applicable)

Parent / Carer 1 Title:

Parent / Carer 1 Forename:

Parent / Carer 1 Surname:

National Insurance Number:

Relationship to child: (e.g. Mother/Father/Carer/ Stepmother/Stepfather/ Social worker etc.)

Parent / Carer 1 Address:

Parent / Carer 1 Email address:

Parent / Carer 1 Mobile Number:

National Asylum Support Service (NASS) Number (if applicable)

Parent / Carer 2 Title:

Parent / Carer 2 Surname:

Parent / Carer 2 Legal Surname:

Parent / Carer 2 Relationship to child: (e.g. Mother/Father/Carer/ Stepmother/Stepfather/ Social worker etc.)

Parent / Carer 2 National Insurance Number:

Parent / Carer 2 National Asylum Support Service (NASS) Number (if applicable)

Parent / Carer 2 Address:

Parent / Carer 2 Email address:

Parent / Carer 2 Mobile Number:

Parent / Carer 2 Daytime Telephone Number:

Additional information to support your application (if applicable):

Declaration: I confirm that the details on this form are correct and to the best of my knowledge.

Print Name of Parent/Carer