Please check the required fields
Date
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Name of Child
*
Gender
*
Male
Female
Date of Birth
*
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2011
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Home Address
*
Borough
*
Home Phone
*
Work Phone
E-mail Address
Names of Parents / Guardians
*
Who is legally responsible for the child?
*
Mum
Dad
Both
Other
Number of Children altogether
*
Place in Family
*
Child's Current Provision
*
e.g. Home, Creche, Other setting
Have they applied elsewhere
No
Yes (Where)
Languages Spoken
Is your child toilet-trained?
*
Yes
No
Any Medical problems / Special needs?
*
No
Yes
Doctors Name
Doctors Address
Doctors Phone Number
Child's Ethnic Group
Religion
Please indicate which you would prefer
*
AM
PM
No preference
Will an interpreter be needed on induction day?
Yes
No
Please Indicate if you are in receipt of one or more of these
Income Support
Income-based Jobseeker's Allowance
Child Tax Credit at a rate higher than the family element
Extra Working Tax Credit relating to a disability
Pension Credit
Financial support from the National Asylum Support Service
None of the above
Where did you hear about Triangle
Would you like us to contact you to arrange a visit to the Nursery?
Yes
No
Security Code:
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