Westgate House, Spital Street, Dartford, Kent, DA1 2EH
Telephone: 01322 277 200
We need some details about your child and family. We have a legal obligation to collect and process this information in accordance with The Early Years Foundation Stage (Welfare Requirements) Regulations 2012 and therefore we do not require your consent for the first section of this form. Where information to be supplied is voluntary or where we do need consent this is identified. The information provided will be uploaded onto our secure software database and used for the purpose of maintaining appropriate contact details and for the safety and well-being of your child.
Childs Full Name
Childs Date of Birth (dd/mm/yyy)
Name the child likes to be known as
Name of parent 1 with whom the child lives
Does this parent have parental responsibility for the child?
If no, do they have legal contact?
Name of parent 2 with whom the child lives
Does this parent have parental responsibility for the child?
Address of parent(s) with whom the child lives:
Home Telephone Number
Mobile Telephone Number (Parent One)
Mobile Telephone Number (Parent Two)
As part of our commitment to reducing unnecessary paper we send invoices, updates and newsletters via email. Are you happy to receive communication in this way?
Name of parent(s) with whom the child does not live
Does this parent have legal contact?
Does this parent have legal access to the child?
Emergency Contact Details
Please provide the names and contact details of 2 people (other than parents/guardians) who we can contact in case of an emergency who can collect your child. Please note that they must be over the age of 18 years of age.
NOTE: It is your responsibility to ensure these people are happy for us to contact them and to hold their details.
Emergency Contact 1
Mobile Telephone Number
Relationship to Child
Emergency Contact 2
A password system operates in our setting. A secure password is required and should be used by emergency contacts and persons authorised to collect your child. Ideally this should be one word and something that is easily memorable. Please do not use obvious things such as middle names. The password is required from anyone colleting your child. If they do not have the password we will not release your child to them.
My secure password is
Persons authorised to collect the child. This is any other adult who may collect your child in your absence. Authorised persons must be over 18 years of age.
Authorised Person 1
Authorised Person 2
We have the safety and well-being of the children in mind at all times and we are sure that you will appreciate that persons known to you are strangers to us and we do need means of identifying those you have authorised to collect your child (either authorised or emergency contacts) when you are unable to.
We as a setting and especially your child/children key person will be familiar with you but we do not always have the opportunity to meet both parents. This is also true of your nominated emergency contacts and authorised persons. We therefore request that should anyone unknown to us be collecting your child that you inform us in advance and show us a photograph to enable us to identify them when they collect your child.
AsthmaHeart ConditionDiabetesSight impairmentEpilepsyKidney / bladder problemsBee sting allergyDeafness
If you have answered yes to any of the boxes above please give details here
Does your child require medication, either long term for existing conditions or life saving drugs such as Ventolin? (Please give details of the medication and dosage)
Does your child have any special dietary needs or preferences?
Does your child have known allergies?
Name of GP
Does your family have a social worker for any reason?
What is the reason for the involvement of Social Services with your family?
Please note that if the child has a child protection plan, these will be obtained from the social worker named above and keep these securely in the child’s named Child Protection file.
The following information is voluntary and you do not have to complete it. However, we have a legitimate interest in requesting this data as it will assist in providing the necessary care for your child and to allow us to monitor and assess their development.
Has your child had their two year old progress check?
If so, on what date was this completed? (dd/mm/yyy)
Are you able to share this information with the setting?
The following section requires information classed as ‘sensitive personal data’ for which we need your consent to collect and process. We request this data as, in some cases we have a contractual obligation to do so with our Local Authority, but also as we have a legitimate interest to allow us to plan and meet your child’s needs.
Ethnicity and Cultural Background
How would you describe your child’s ethnicity/cultural background?
What is the main religion of your family?
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 s/he is in our setting?
What is/are the main language(s) spoken at home?
If English is an additional language, will this be your child’s first experience of being in an English-speaking environment?
Special Educational Needs and Disabilities
Does your child have any special needs or disabilities?
If yes please give details below
What (if any) special support will your child require in our setting?
Professionals involved with the child
Professional 1 Name
Professional 1 Agency
Professional 1 Role
Professional 1 Telephone Number
Professional 2 Name
Professional 2 Agency
Professional 2 Role
Professional 2 Telephone Number
The following section contains information for which we need your consent. As required by data protection we have a duty to inform you that you can withdraw your consent for any of the permissions detailed below at any time. Should you wish to withdraw consent please discuss this with a member of staff in the first instance.
Permissions and Consent
Permission for the setting to act in loco parentis
If emergency treatment is required, either whilst your child is on the premises or on an outing, (for the duration of your child’s time with us) and the parents or legal guardians cannot be reached immediately, your signature in the space provided below empowers the settings management to exercise their own judgement in calling the doctor/dentist indicated above or to transport the child to a hospital casualty department by ambulance. Please read and fill in the declaration below, and sign and date this section.
I / We parent(s)/guardian(s) of DoDo Not give consent on my / our behalf for an anaesthetic to be administered or for any other urgent medical treatment to be given.
I / We do not agree to this statement and indicate our wishes as follows:
Permission for the application of sun cream
I give permission for KTB Kids Day Nursery to apply their own supply of high factor children’s sun cream to my child.
Administration of Calpol consent form
KTB Kids will administer a maximum of 5ml of Calpol in the situation of your child having a raised temperature and in accordance with our Medication Policy. Calpol will only be given following telephone contact with the parent/ guardian as an interim measure whilst waiting for the child to be collected from the nursery. KTB Kids will not administer Calpol in any other circumstances apart from those set out in the Medication Policy.
I give permission for KTB Kids Day Nursery to administer a maximum of 5ml of Calpol to my child in line with the administration of medicine policy.
Please tick the statements below if you consent to the following:
I consent to my child participating in off-site outings as part of daily practice e.g. trips to the park, shops, etcI consent to my child participating in off-site outings as part of daily practice using public transport to further benefit from the wider communityI consent to my child having their photograph taken for use in displays, for name pegs, etc within the settingI consent to my child having their photograph taken to be used for publicity purposes – website, flyers.I consent to my child’s photograph being used on the settings social media sitesI consent to my child’s artwork (with their name) being displayed in the settingI consent to my child’s photograph being used in learning journeys of other children within the settingI consent to my child being videoed for use by the setting staff only with regards to observational purposes either assessment of children, an activity or for monitoring children’s behaviourI consent to the video, as mentioned above, to be shared with other professionals visiting the group such as Early Years Advisors, SENCO, Health Visitor etc if necessaryI consent to my child’s learning journey being shared with Ofsted inspectors and/or as part of audits by the local authorityI give permission for an online LearningBook Learning Journal to be created and maintained for my child.I give my consent for my child to have face paints applied.
Please sign below to confirm your consent for the indicated statements above:
Further information regarding how we use children’s images within the setting can be found in our Image Use Policy.
SPECIAL NOTE: Please notify us immediately of any changes to the information provided. Please feel free to come and discuss any problems or concerns with us. If there are any other notes you would like to add, please use the space below.
I / We confirm that the information provided on this form is correct to the best of our knowledge. I understand that there is a one month notice period to terminate my contract at the nursery and that there are penalty fees for late collection and late payment. I have been sent the KTB Kids Admissions Handbook and am happy with the nursery practices and policies.
Signature of Parent (s)/Carer (s)
Agreed start date at nursery (dd/mm/yyy):