Please print this page and bring it along to the playgroup during opening hours when completed.

Chewton Common Playgroup Highcliffe St Marks Primary School Greenways Highcliffe BH23 5AZ 07814 700414   APPLICATION FORM

Childs full name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Name by which child is known . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Home address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Home telephone number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Childs date of birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Parents name and address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Parents place of employment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Work telephone number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Emergency contact number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Emergency contact name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Name of G.P. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Address of G.P. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Telephone number of G.P. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Health visitors telephone number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Who should the child be collected by . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Your child's health details:-   Does your child have any disabilities? Yes / No Does your child have any illness? Yes / No Does your child require any medication? Yes / No Does you child have a special diet? Yes / No Does your child have any allergies? Yes / No If you have answered yes to any of these questions or have any relevant information regarding cultural or religious beliefs, please give details on the back of this form. Please give immunisation details on the back of this form. Please return this form to the Scout Hut during Playgroup hours.