Admission Form

Child's Details

Date of Birth *

Gender *

First Name *

Surname *

Class *

Address *

Postcode *

Preferred choice of name if any

Name of First Parent/Guardian Living at Home Address Above

Title *

First Name *

Surname *

Relationship to Child *

Parental Responsibility *

Home Telephone Number *

Mobile No.

Work Telephone Number *

Work Place *

Name of Second Parent/Guardian

Title *

First Name *

Surname *

Relationship to Child *

Parental Responsibility? *

Mobile Phone Number

Work Telephone Number

Work Place

Address (if different)

Other children in the family name(s) and date of birth

Emergency Contact Details

Name of Doctor *

Telephone Number *

Practice address *

Post Code *

Name(s) * Other local contacts in case of emergency or illness at school

Telephone Number Telephone Number

Emergency Password *

Person 1 *

Person 2

Person 3

Supplementary Details

Is the child/family is known to social services or any other agency? *

If yes - Please details

Did your child attend any previous school? *

If yes - Please enter your school name and address

Has your child had any serious illnesses or injuries? *

If yes - Please details

Has your child completed an immunization program to date? *

If yes - Please details

Has your child any known allergies and medical conditions? *

If yes - Please details

Does your child have any particular or special needs *

If yes - Please details

Does your child have any fears? *

If yes - Please details

Does your child drink milk/eat dairy product? *

If yes - Please details

Languages spoken at home *

Please state child’s religion/culture *

Permission

There is CCTV being recorded for safety and security purposes.I agree to mychild being recorded on the CCTV system for the above purposes.

Signature *

Date *

Occasionally we may take the child away from the premises for a walk,to the mosque, leisure centre post box or the park.I give my permission for my child to take part in the seactivities

Signature *

Date *

Photographs are used to track children’s learning, in newsletters,displays,websites,pre-school public ationsand local newspapers I give my permission for my child to be photographed for the above reasons

Signature *

Date *

I give my permission for a trained first aider to administer first aid to mychild.

Signature *

Date *

Any other information you think would be helpful for us to know about your child.

Other helpful information

Your child will be placed on the waiting list and contacted when a place becomes available.

Thank you for telling us about your child, we look forward to your child joining us and enjoying their time at Dar ul Madinah Leicester

Declaration

I confirm all the details completed in this form are true and accurate. I will inform Dar ul Madinah of any changes immediately.

Sign *

Date *

Print Name *

Parent/Career

Any information given to the pre-school as part of this application/registration form will be treated with the strictest of confidence. Any Data collected will be, fairly and lawfully processed, for limited purposes, adequate, relevant and not excessive, accurate, not kept longer than is necessary, processed in accordance with the data’s subjects rights, held securely and not transferred to other organizations unless required to do so by Ofsted, health and safety legislation or other legal obligations.

Admission Form

Child's Details

Name of First Parent/Guardian Living at Home Address Above

Name of Second Parent/Guardian

Emergency Contact Details

Supplementary Details

Permission

Declaration

0116 319 1040

[email protected]

Darul Madinah Leicester, Malabar Rd, Leicester LE1 2LG

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