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Acorns Wraparound Care
Registration Form
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Child's Full Name
Your answer
Date of Birth
MM
/
DD
/
YYYY
1st Parent/Guardian Name
Your answer
Home Address
Your answer
Does the child live at this address?
Yes
No
Clear selection
Does this parent have parental responsibility for this child?
Yes
No
Clear selection
Relationship to child
Your answer
Email address
Your answer
Telephone Number
Your answer
2nd Parent/Carer Name
Your answer
Home Address
Your answer
Does the child live at this address?
Yes
No
Clear selection
Does this parent have parental responsibility for this child?
Yes
No
Clear selection
Relationship to child
Your answer
Email Address
Your answer
Telephone Number
Your answer
Emergency Contact Details
Your answer
Does your child have any allergies or medical conditions? If so, please give details of these below.
Your answer
Are there any other specific needs/concerns that we need to be aware of? If so, please give details below.
Your answer
Doctors Name
Your answer
Doctors Address and Telephone Number
Your answer
Consents
: I give my consent as Parent/Guardian of the above named child for the following (please tick as appropriate).
First aid to be administered to my child by a trained staff member
Prescribed medicine to be administered by a trained staff member
Sunscreen to be applied by a staff member of if necessary
Acorns Wraparound Care staff to sign consent for further treatment by medical staff if parent is delayed/danger to life
Acorns Wraparound Care staff to liase with school to support child's welfare - emotional/behavioral/medical/SEND
I undertake to inform Acorns Wraparound Care of any concerns, medical changes, change in circumstances or change of address
Media (social)
Media (paper)
Image for Newsletters/Displays
Website/Screen
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