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Child Registration Form

Child’s Details

Child’s Name(*)
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Preferred Name(*)
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Date of Birth(*)
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Gender(*)
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School Attended
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Parent/Carer Details

Name of Parent/Carer(*)
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Home Address(*)
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Post Code:(*)
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Main Contact Number:(*)
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Alternative Number:
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Work Contact Number
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Email Address(*)
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IMPORTANT: Confirmation will be sent to this address.

Who has the parental Responsibility:
Parent/Carer 1:
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Parent/Carer 2
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Names of Authorised person to collect your child
Person 1 - Full Name(*)
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Main Contact Number:(*)
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Relationship with Child:(*)
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Person 2 - Full Name
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Main Contact Number:
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Relationship with Child:
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Emergency Contact Details

Emergency Contact Details 1
Contact Name(*)
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Main Contact Number(*)
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Alternative Number:
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Work Contact Number
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Emergency Contact Details 2
Contact Name
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Main Contact Number:
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Alternative Number:
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Work Contact Number
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Details of Social/Support Worker

Social Worker’s Name
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Contact No
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Support Worker's Name:
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Contact No
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Additional Needs

Does your child have any additional needs or disability?(*)
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If YES please state
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Is your child a wheelchair user?(*)
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Details of any significant health issues
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Does your child have any allergies?(*)
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Details
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Does your child have any dietary requirement?(*)
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Details
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Is your child able to take food/drink by mouth?(*)
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Medical Information

Child’s medical number
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Doctor’s Name
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Doctor’s Address
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Doctor’s Telephone Number
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Is your child taking any Medicine?(*)
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Any other relevant medical information
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Routine Outings with Log Cabin(*)
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I agree that my child may go on trips, visits and outings with the Log Cabin.

Transporting in a Vehicle(*)
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I agree that Child may be transported in an appropriately insured vehicle or by public transport by the Log Cabin.

Observations(*)
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I agree and understand that ongoing observations will be undertaken on my child to follow and assess their progress in development – these may be in the form of written statements, photographs, video or tape recordings.

Emergency Medical Treatment(*)
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My child may be transported to hospital with any member of Log Cabin staff in the event of medical emergency.

Confidentiality(*)
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I agree that the information I have given may be shared with other professional organisations

Photograph(*)
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I consent for my child to be photographed/videoed for the use of publicity material for the Log Cabin (website, promotional material, display purpose, fundraising activities)

 

Equal Opportunities

How did you hear about the Log Cabin
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Equal Opportunities Monitoring


The Log Cabin is committed to ensuring equality of opportunity for people who use our services for our staff and volunteers. A copy of the full Equal Opportunities Policy is available upon request. You are not obliged to fill this form in. However, this information helps us monitor the progress of our Equal Opportunities policy. Please fill in the details below on behalf of your child and return. This information will be treated in the strictest confidence and will be used for monitoring purpose only. The information on this form will not be used as part of the application process. We will not pass on information about you to anyone outside Log Cabin.

Ethnic Background:

Monitoring details- please tick the appropriate box/boxes, relating to your child(*)
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Other please specify
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Gender
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Does your child have a disability or special need?
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Disclaimer

Disclaimer
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I have agreed to submit this application by electronic means. By signing this application electronically, I also certify that: I understand the questions and statements on this application. I understand that an electronic signature has the same legal effect as written signature.

I confirm that I am happy for this application to be processed on my child and partners behalf.
I confirm that I am 18 or over.

Our Location

The Log Cabin
259 Northfield Avenue, W5 4UA

  • Registered Charity No: 275183

Office opening hours

Mon-Fri: 11am - 6pm

Sat & Sun: closed