Arty Em's Child Record Form
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Email *
Contract or Flexible use? *
If you selected 'Contract' above please indicate the days and times you require.
If you require Flexible childcare please book your place at Breakfast Club the night before at the latest and for After School Club please book by 2.30pm on the day you require care.
1st Childs Full Name *
1st Childs Date of Birth *
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2nd Childs Full Name
2nd Childs Date of Birth
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DD
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YYYY
3rd Childs Full Name
3rd Childs Date of Birth
MM
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DD
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YYYY
Parent/carer information
It is a legal requirement to provide the full details of both parent/carers of the child named above, regardless of your current relationship/marital status. This is to ensure that we can protect and maintain your child's safety and wellbeing.
No.1 Parent/carers contact details - 
Name 
Address  
Telephone number
 *
No.1 Parent/carers Occupation *
No.2 Parent/carers contact details - 
Name 
Address 
Email  
Telephone number
 *
No.2 Parent/carers Occupation *
Who does the child/children named above live with? *
Do you have an active Court Order regarding the care of the child/children named above? *
If you answered 'Yes' to the above question please send a copy of the Court Order to artyemshr@gmail.com
Medical Information and Emergency Contact Information
Emergency Contact Details (name and telephone number) and their relationship to the child named above (please provide 2 emergency contacts). *
COLLECTING YOUR CHILD FROM THE AFTER SCHOOL CLUB

Your child will not be permitted to leave the club with anyone other than yourself or named persons on this contract without prior arrangement. In the case of an emergency you should contact the club with details of who will collect your child and you will be asked to provide a password that you and your trusted person have agreed so that we can ensure your child is collected by an authorised person known to you.

Please provide password for your child/children  *

Provide a password should you require your child to be collected by a trusted relative/person not known to Arty Em’s staff

Name and contact number of the Doctors your child is registered with *
Is your child/children up to date on their childhood immunisations? *

Are you aware of any medical conditions your child has currently? If yes please list. (Please specify which child this relates to)

Is your child currently on any long term medication/receiving treatment? Please specify below what medication(s)/treatments. (Please specify which child this relates to)
Are you aware of any allergies your child currently has?  *
If you answered 'Yes' to the above question please specify the allergies below. (Please specify which child this relates to)

Do you or your child/children have any specific requirements? (Cultural/ethical/SEND) if so please state here

 *
Permissions *

Your child’s safety and wellbeing is at the very core of Arty Em’s Breakfast and After School Club therefore we require the following permissions to be completed by the child’s parent/carer to ensure that we can maintain their wellbeing whilst within our care. 

Whilst attending the breakfast/after school club do you the parent/carer give consent for your child to participate in the following: 

Required
Digital signature
Our policies, procedures, terms and conditions are all available to view on our website artyems.weebly.com
Details of the person signing:
Full Name
Relationship to the child/children 
Date digitally signed
Please answer below:
 *
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