Registration Form Please enable JavaScript in your browser to complete this form.Child's Name *FirstMiddleLastNickname (What he/she likes to be called)Date of birth *Gender *MaleFemalePrimary languageEnglishAfrikannsAlbanianArabicArmenianBasqueBengaliBulgarianCatalanCambodianChinese (Mandarin)CroationCzechDanishDutchEstonianFijiFinnishFrenchGeorgianGermanGreekGujaratiHebrewHindiHungarianIcelandicIndonesianIrishItalianJapaneseJavaneseKoreanLatinLatvianLithuanianMacedonianMalayMalayalamMalteseMaoriMarathiMongolianNepaliNorwegianPersianPolishPortuguesePunjabiQuechuaRomanianRussianSamoanSerbianSlovakSlovenianSpanishSwahiliSwedishTamilTatarTeluguThaiTibetanTongaTurkishUkranianUrduUzbekVietnameseWelshXhosaSchool AttendedFairfield Primary SchoolLunt's Heath Primary SchoolHallwood Park Primary SchoolOtherChild's year / classNew September StarterReception - Gruffalos (J Brame)Reception - Unicorns (S Dilworth)Reception - Ladybirds (L Webb)Year 1 - Giraffes (C Stewart)Year 1 - Dolphins (F Chamberlain)Year 1 - Turtles (J Wilson)Year 2 - Super Dinosaurs (J Burgess)Year 2 - Happy Hedgehogs (J Redhead)Year 2 - Owl Babies (E Filer)Year 3 - Power Crystals (C Dumbell)Year 3 - Biscuit Billionaire (L Rizzotti)Year 3 - Secret Hideout (P Goulding)Year 4 - The Wildsparks (G McNicholas)Year 4 - Bright Storms (E Monks)Year 4 - Fire Songs (B Smith)Year 5 - Hufflepuffs (R Scott)Year 5 - Gryffindors (E Griffiths)Year 5 - Ravenclaw (V Harrison/N Sheil)Year 6 - Eriadors (C Davies)Year 6 - Rivendells (J Donnolly)Year 6 - Lochloriens (S Sheridan)Child's year / classNew September StarterReception (RH)Reception (RL)Year 1 (1H)Year 1 (1L)Year 2 (2H)Year 2 (2L)Year 3 (3H)Year 3 (3L)Year 4 (4H)Year 4 (4L)Year 5 (5H)Year 5 (5L)Year 6 (6H)Year 6 (6L)Child's year / classNew September StarterReceptionYear 1Year 2Year 3Year 4Year 5Year 6Requested Permanent Bookings Each Week *Monday AMMonday PMTuesday AMTuesday PMWednesday AMWednesday PMThursday AMThursday PMFriday AMFriday PMAd hoc / Holiday Club Bookings OnlyRequested Permanent Bookings Each Week *Monday PMTuesday PMWednesday PMThursday PMFriday PMAd hoc / Holiday Club Bookings OnlyRequested Permanent Bookings Each Week *Ad hoc / Holiday Club Bookings OnlyBooking Notes (if applicable)Requested Start Date (Week Commencing) *1st Parent / Legal Guardian DetailsThis should be the child's legal Parent/Guardian (We will use these details as the main contact and for invoicing).Title *MrMrsMissMsOtherTitleName *FirstLastHome Address *Address Line 1CityState / Province / RegionPostal CodeDoes the child normally live at this address? *YesNoWork AddressAddress Line 1CityState / Province / RegionPostal CodeHome Telephone NumberMobile Telephone Number *Work Telephone NumberEmail *EmailConfirm EmailOur primary form of communication is by email. Please supply us with an email address that will be checked regularly.2nd Parent / Guardian DetailsTitleMrMrsMissMsOtherTitleNameFirstLastDifferent home address to 1st Parent/Guardian?YesHome AddressAddress Line 1CityState / Province / RegionPostal CodeWork AddressAddress Line 1CityState / Province / RegionPostal CodeHome Telephone NumberMobile Telephone NumberWork Telephone NumberEmailEmailConfirm EmailDoes anyone else have parental responsibility for this child?YesNoPlease provide detailsEmergency Contact Details OnePlease provide details of two people we can contact if weare unable to reach the Parents/Guardians detailed aboveName *Relationship to child *Home Telephone NumberMobile Telephone NumberWork Telephone NumberAddress/Place of WorkEmergency Contact Details TwoNameRelationship to childHome Telephone NumberMobile Telephone NumberWork Telephone NumberAddress/Place of WorkCollection Password *Should you wish to allow an alternative adult to collect your child, we use a password system.You should provide us with a suitable password which we can use to challenge anyone collecting your child who we do not know.Child's Medical DetailsDoctor's name *Surgery *Appleton Village Surgery - 0151 423 2990Beeches Medical Centre - 0151 424 3101Bevan Group Practice (Bevan Way) - 0151 424 3986Bevan Group Practice (West Bank) - 0151 424 3986Hale Village Surgery - 0151 511 5720Hough Green Health Park - 0151 511 5805Newtown Surgery - 0151 495 5110Oaks Place Surgery - 0151 595 5140Peelhouse Medical Plaza - 0151 424 6221Upton Rocks Primary Care - 0151 511 5730Widnes GP Health Centre - 0151 495 5249OtherDetailsPlease provide the surgery name and telephone numberDetails of any Significant Health Issues (including additional/special needs and/or physical disabilities)Provide details of any professionals involved with the family / child or if subject to a multi-agency planStaff Ratios / Supporting Your Child *Please tick to confirm you have read, understand and agree to the following.Our normal staffing ratios are between 1:8 and 1:10 for children under 8 years old and between 1:10 and 1:15 for children 8 years and over. If your child's support needs are unable to be met within our normal staffing structure and ratios, it is unlikely we will be able to accept your registration. You should contact us to discuss this before submitting a registration form if this may be the case.Toilet needs *Please tick to confirm you have read, understand and agree to the following.If your child is not fully toilet trained, we do not have facilities available or have staff ratios necessary to attend to children who have toilet accidents.Parents will always be called to attend in such instances and we therefore ask this be consider prior to making any bookings.Our recommendation is to avoid making bookings if you child has had any accidents in the previous half term (or in the previous 6 weeks for new Reception starters).About your childDetail of any special dietary requirements / food allergiesIs there anything your child doesn’t like (food, games etc) or is scared of?What are your child’s favourite activities?PermissionsAs the parent or carer of the child named below, I grant permission for images of my son or daughter to be used for the following purposesElectronic and printed displays and exhibitions at the Club (eg photos of activities)Observation and assessment of my child’s progressClub records of my childTo accompany staff or student courseworkClub’s official websiteClub’s official social media account (eg. Facebook, Twitter)Promotional material for the Club (eg. flier, advert, poster)Local newspaper or magazineNational newspaper or magazineOther organisation’s websiteOther organisation’s promotional materialOtherThe use of photographs is an important developmental tool which is widely used in play and educational settings for recording, sharing and displaying activities that your children have undertaken. At Kid’s Space Limited we take the issue of child protection very seriously and we would never knowingly publish an image of your child without consent. Personal details or names of any child in a photograph will never be given in such a way that would allow them to be individually identified (except when used in the child’s own records). Images will NOT be used for anything which may be viewed as negative in tone or that may cause offence, embarrassment or distress for the child or their parent or carer.I am happy for my child to have sunscreen applied at Kid’s Space *NoYes. I am happy for my child to use the sunscreen provided by the ClubYes. I will provide a bottle of sunscreen labelled with my child’s name for use at the ClubKid’s Space Limited is concerned about protecting your child from sunburn and skin damage. Please provide a suitable hat, such as a legionnaire’s hat or sunhat. On sunny days apply sunscreen to any exposed parts. With your consent we will also help your child apply sunscreen when necessary.Working Together to Support Our Children *Tick to confirm agreement of the following:I hereby consent to Kid's Space Limited Before and After School Club and Fairfield Primary School sharing relevant information about my child to support their development and well being.Working Together to Support Our Children *Tick to confirm agreement of the following:I hereby consent to Kid's Space Limited Before and After School Club and Lunt's Heath Primary School sharing relevant information about my child to support their development and well being.Working Together to Support Our Children *Tick to confirm agreement of the following:I hereby consent to Kid's Space Limited Before and After School Club and Hallwood Park Primary School sharing relevant information about my child to support their development and well being.Working Together to Support Our Children *Tick to confirm agreement of the following:I hereby consent to Kid's Space Limited and my child's School sharing relevant information about my child to support their development and well being.Agreement *Tick to confirm agreement of the following:I hereby consent for my child to take up a place at Kid's Space Limited according to the Terms & Conditions set out in the Policies, Procedures and the Club Handbook. I have understood the expectations and obligations relating to both myself and the club and agree to abide by them. I understand that persistent late or non payment of fees will jeopardise my child's continued attendance at the club. I confirm the above information above is correct and I will update the club with any changes.GDPR Agreement *I consent to my details being transmitted by email to Kid's Space Limited. All information will be kept confidential in line with our Data Protection Policy and our Privacy Notice.Electronic Signature *Confirm with YOUR date of birth *NameSubmit
