Southmead+ Registration Form
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Child's Surname *
Child's Forename *
Child's Date of Birth *
Home Address *
Home Phone Number *
Child's Class *
First Parent Title *
First Parent Surname *
First Parent Forename *
First Parent Address (inc. postcode) *
First Parent Home Phone Number *
First Parent Mobile Phone Number *
First Parent email address *
Relationship to pupil *
Do you have parental responsibility? *
Required
Contact priority *
Required
Authorised to collect pupil *
Required
Second Parent Title
Second Parent Surname
Second Parent Forename
Second Parent Address (inc. postcode)
Second Parent Home Phone Number
Second Parent Mobile Phone Number
Second Parent email address
Relationship to pupil
Do you have parental responsibility?
Contact priority
Authorised to collect pupil
Additional Contact Title
Additional Contact Surname
Additional Contact Forename
Additional Contact Address (inc. postcode)
Additional Contact  Home Phone Number
Additional Contact Mobile Phone Number
Additional Contact email address
Relationship to pupil
Do you have parental responsibility?
Contact priority
Authorised to collect pupil
Dietary Requirements
Dietary requirements (tick all that apply) *
Required
Does your child have any other dietary requirements that the school should be aware of?
Medical Information
Does your child have any medical conditions we should be aware of? If yes, please state:  
 *
Medical practice name
 *
Medical practice phone number
 *
GP Name
 *
Does he / she take medication?
*
Do we have medication in school? 
 *
If Yes where is it kept? 
When should it be given? 
Can they self-administer medication?     
Clear selection
Does he / she have any allergies?
Clear selection
If yes, what are they?
Additional Information
Does your child have a special need of any description?
 *
Does your child have a  statement of special educational needs?
 *
Disabilities
Has he / she any physical disability? (Including deafness, poor sight etc)
*
Does he / she have any aids (hearing aid, glasses etc) and is he / she willing to use them?
*
Do these disabilities cause any problems? If so, what are they?
 *

Behaviour

What is his / her behaviour generally like?
 *
Does he / she have any behaviour problems?
*
If ‘yes’ what are they? (ie temper tantrums, tearfulness, nervous habits, including self-inflicted hurts, hair pulling etc)
What are their triggers?
What calms them?
*
Yes
No
Is your child verbally aggressive?
Is your child physically aggressive?
Is your child shy or withdrawn?
Do they have any fears?
If Yes what are they?  
Is there anything else you think we should know?
*

Leisure Activities / Communication

What does he / she especially like doing?
*
What doesn’t he / she like doing?
*
Does he / she enjoy shopping trips?         
 *
Can he / she talk so that other people can understand them?   
 *

Does he / she use other ways of telling you they want something?  If so, please tell us how they do it and for what e.g. going to the toilet, a drink, a particular toy etc 

 *
Does he / she use Makaton signing?  
 *
Permissions

All Parents / Carers must complete this section.  Children cannot be accepted unless this form is signed and dated.
I consent to my child attending Southmead Breakfast and Afterschool Clubs and participate in daily activities including, organised trips off the premises, and give authority to Southmead Staff to act on my behalf in the event of an emergency, including authority to give consent to doctors or paramedics to administer medication in the treatment of my child.  I consent to staff administering sun protection as necessary.  I agree to pay all fees that occur from the use of the services provided and abide by the policies and procedures e.g. behaviour management.

Please tick to say you agree:

 *
Required

Permission for photographs and digital images:

From time to time we may take photographs and videos of the children at the clubs. Please confirm the existing consents given to Southmead Primary School regarding photographs and images of your child are to apply for the Breakfast and Afterschool Club.

I understand that I can change my permission by contacting the school office.

 *

Friday Afterschool Club
On Fridays at Afterschool club we may show a film.  The children may request a PG rated film in order to show this we need your permission. 
I give permission for my child to watch a PG rated film in Afterschool Club

I understand that I can change my permission by contacting the school office. 

 *
If you would like your Year 4 or above child to walk home from Afterschool Club please discuss with Mrs Drescher or Mrs Parr in the first instance.

Password

Please provide a password to be used in the event of you not being able to pick up your child and arrange for someone else to collect.  On arrival at the club they will require your password to authorise the collection of your child.

 *
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