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Acorns Early Years Registration Form
Westbourne Park Family Centre, Westbourne Park Baptist Church, Porchester Road, London W2 5DX
Tel. 020 7727 6019, Charity No. 1085070
Please fill out the registration form. Many thanks.
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* Indicates required question
Your Name and Surname
*
Your answer
Relation to Child
*
Mum
Dad
Other relative
Childminder
Nanny
Other:
Email
*
Your answer
Address
*
Your answer
Postcode
*
Your answer
Which ward do you live in?
Westbourne
Bayswater
Harrow Road
Lancaster Gate
Other:
Clear selection
Phone number
Your answer
Would you like to recieve information (ie updates, change of times, upcoming events etc) through WhatsApp group? (only admins can post)
Yes
No
Clear selection
How did you hear about us?
Family member/ friend
Visiting the Children's Library
Passing the building
Poster or leaflet
Social media
Online search
Other:
Clear selection
Name of Child
*
Your answer
Name of Second Child
Your answer
Child's Date of Birth
MM
/
DD
/
YYYY
Second Child's Date of Birth
MM
/
DD
/
YYYY
Child's ethnic Background
Your answer
Child's gender
Female
Male
Clear selection
Second Child's gender
Female
Male
Clear selection
Are you a single parent?
Yes
No
Prefer not to say
Clear selection
Does your child have any additional/special needs? If yes, please advise.
Your answer
Do you have any additional/special needs? If yes, please advise.
Your answer
Parent/Carer ethnic background
Column 1
Asian or Asian British
Black, Black British, Caribbean or African
Mixed or multiple ethnic groups
White
Other ethnicity
Column 1
Asian or Asian British
Black, Black British, Caribbean or African
Mixed or multiple ethnic groups
White
Other ethnicity
Clear selection
Parent/Carer age
0-19
20-24
25-64
65 and over
Clear selection
Parent/Carer first language
Your answer
Parent/ Carer gender
Female
Male
Prefer not to say
Other:
Clear selection
Parent/Carer religion
No religion
Hindu
Christian
Buddhist
Jewish
Muslim
Sikh
Other religion
Prefer not to say
Clear selection
As a Charity, WPFC has a focus on supporting families on low income. Do you receive benefits?
*
Yes
No
Data Consent
Westbourne park Family Centre will keep your details secure and not share them with any other organisation without your consent. If you have any questions or want your data changed at any time, contact:
info@westbourneparkfamilycentre.org.uk
Do you give permission for these details to be used anonymously as part of an evaluation of our services and their impact?
Yes
No
Clear selection
We occasionally take photographs for promotion and funding purpose. Do you give us permission to do this
Yes
No
If we ask at the time
Are you interested in volunteering to suport these sessions?
Yes
No
We would like to ask you a few questions so we can have an idea about where you and your child are and how we can journey with you.
These questions for parents only. Your answers are completely confidential.
When answering the questions, please consider your childs age. And if you feel any of it is intrusive, please talk to Suna, 07467274716.
Thank you!
Your answer
On a scale of 1 to 5, how self confident is your child?
Not confident
1
2
3
4
5
Very confident
Clear selection
Do you feel your childs use of language (ie babbling for babies) is appropriate for their age? On a scale of 1 to 5..
Not appropriate
1
2
3
4
5
Very appropriate
Clear selection
In your opinion, how ready is your child for nursey/ school ?
Not ready at all
1
2
3
4
5
Ready to go
Clear selection
On a scale of 1 to 5, how connected do you feel socially?
Not connected
1
2
3
4
5
Very connected
Clear selection
How confident are you with your parenting skills?
Not confident
1
2
3
4
5
Very confident
Clear selection
Do you feel you have bonded well with your child?
Not very well
1
2
3
4
5
Very well
Clear selection
Print Name
Your answer
Date
MM
/
DD
/
YYYY
Submit
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