1. Child’s first name: *

2. Child's surname: *

3. Name child to be known as if different to the above:

4. Date of Birth *

YYYY

For the purpose of Department of Education Annual Census we are required to collect the following information:

5. Please state your child's religion: *

Protestant

Catholic

Other (Please Specify Below)

6. Languages Spoken: *

English

Irish

Other (Please Specify Below)

We now need to ask you some medical information about your child:

7. What is your child's Health and Social Care Number? (this can be found in the red book you were given for your child when they were born or on any hospital appointment letters that you may have received for them)

8. Name of GP and clinic details: *

9. Name of Health Visitor: *

10. Has your child had any significant childhood illness? *

Yes

Other (Please Specify Below)

11.

Do we need to know about any important diagnosed health considerations for your child? (please give details and any special requirements)

Yes- please add details below

Comment

12. Is your child taking any ongoing or regular medication? *

Yes- please add details below

Comment

13. Does your child have any allergies that we need to know about? *

Yes- please add details below

Comment

14. Is there any information or family history that we need to know about such as: birth problems, prematurity, separation, bereavement, important events *

Yes- please add details below

Comment

15. Does your child have any professionally diagnosed dietary needs? *

Yes- please add details below

Comment

16. Does your child require help or assistance when using the toilet? *

Yes- please add details below

Comment

17. Does your child have any cultural or religious requirements? *

Yes- please add details below

Comment

18. Does your child have any fears or phobias that we need to know about? *

Yes- please add details below

Comment

CHILD PROTECTION PERMISSIONS

Please select either agree or disagree to the following list of questions. *

19. I give permissions for photographs and videos of my child to be used for displays and videos in school classrooms and shared areas within the Nursery. *

Agree

Disagree

20. I give permission for photographs and videos of my child to be used on the the school website. (Password protected class pages) *

Agree

Disagree

21. I give my permission for photographs and videos of my child to be used for the presentations, training of staff and promotion of the school on the school website- public pages, and for example in the Nursery Parents Information booklet. *

Agree

Disagree

22.

I give my permission for staff to reapply sun cream if my child requires it.

Agree

Disagree

23.

I give my permission for staff to clean and undress my child if they have a toileting accident, are unwell or are hurt and require medical attention.

Agree

Disagree

24.

I give my permission for staff to take my child on short walks around the local area for example to Primary school events, the library etc. (Parents and Carers will always be notified prior to any instance of children being taken out of school)

Agree

Disagree

25.

I am happy for my child to be videoed during events

Agree

Disagree

26. I am happy for my child to have face paint applied at events if applicable *

Agree

Disagree

27.

I understand that I can read the policies for Child Protection- (including how to raise a child protection concern) and GDPR, as listed at the beginning of this questionnaire, on the school website.

Agree

Disagree

28. School Fund.
Please indicate how you will be paying for your child's school fund this year: *

Monthly - £15 (in the monthly envelope sent home)

Termly- £40 by bank transfer

One payment £120- by bank transfer (before the end of October)

29. Name of person completing this form: *

30. Please indicate your relationship to the child: *

Mother

Father

Legal Guardian

Other (Please Specify Below)

Comment

PARENTAL RESPONSIBILITY

A mother automatically has parental responsibility for her child from birth.

A father usually has parental responsibility if he’s either:

married to the child’s mother
listed on the birth certificate (after a certain date, depending on which part of the UK the child was born in)

Births registered in Northern Ireland:

A father has parental responsibility if he’s married to the mother at the time of the child’s birth.

If a father marries the mother after the child’s birth, he has parental responsibility if he lives in Northern Ireland at the time of the marriage.

An unmarried father has parental responsibility if he’s named, or becomes named, on the child’s birth certificate (from 15 April 2002).

31. I confirm that I have legal parental responsibility or guardianship for my child as outlined in the information above:

Yes

Other (Please Specify Below)

Comment

Orange Class Entry Profile 2025