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Date

/ /

Name of Child *

Gender *

Date of Birth *

/ /

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

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?

Security Code: *

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