Pre-School Centre

First name

Surname

Name your child is known by

MaleFemale

Date of birth

Nationality

Religion

Home Language

Does your child have any allergies?

Does your child have any medical conditions?

Does your child have any learning difficulties or disabilities?

If known, please select as appropriate

No Special Educational Needs Early Years Action Early Years Action Plus Statement

Mother's name

Occupation and workplace

Mother's Address

Postcode

Home number

Mobile number

Email address

Father's name

Occupation and workplace

Father's Address

Postcode

Home number

Mobile number

Email address

Please indicate which address the child normally lives at

Who has parental responsibility for the child?

Mother Father Both Parents Carer Children's Social Care

Who is the legal contact for the child?

Mother Father Both Parents Carer Children's Social Care

Has your child attended another child care setting?

Yes No If yes, please state name and contact details

Will your child attending another setting whilst attending the Pre-School Centre?

Yes No If yes, please give contact details

Please specify appropriate category for this application

Member of staff at Lancaster University Undergraduate student of Lancaster University Postgraduate Student of Lancaster University Other

Students

Name of College Course Library Number

Staff

Name of Department

Do you require full or part-time care?

If part-time, please indicate the number of sessions required.

(A session is morning or afternoon)

Please indicate a provisional start date

Please note this is an application form only, which will be held on the waiting list prior to a booking form being issued and a place being allocated.

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