New Child Registration Form

Contact

GDPR / Data Privacy Statement

We collect this information to ensure that we can provide the right level of care and support for your child.

All personal information is stored securely and processed in accordance with the UK GDPR and the Data Protection Act 2018.

• Information will be kept confidential and shared only with professionals involved in your child’s care and only with your consent, unless we are legally required to do otherwise for safeguarding reasons.

• You have the right to request access to the information we hold about your child, request corrections, or withdraw consent at any time.

• Data will be stored only for as long as necessary and then securely deleted.

If you wish to withdraw consent, request a copy of data held or raise a concern, please contact the Data Protection Lead by email: newtonlangcc@gmail.com

I consent to have this website store my submitted information so they can respond to my inquiry

CHILD DETAILS

Please enter the details of the child who you are registering for.

Your Email

First Name

Middle Name

Last Name

Known as

Date of Birth

Gender

Primary Language

English

Other

Ethnicity

Other Ethnicity

School

Other School

School Year

Name of Sibling Currently at Club

Password to be Used Upon Collection

Intended Start Date

Child Address

Address Line 1

Address Line 2

City

County

Post Code

Do you want to register a second child?

Yes

SECOND CHILD DETAILS

Please enter the details of the second child that you are registering for.

Second Child First Name

Middle Name

Surname

Known as

Date of Birth

Gender

Primary Language

English

Other

Ethnicity

Other Ethnicity

School

Other School

School Year

Name of Sibling Currently at Club

Same address as first child?

Yes

Second Child Address

Address Line 1

Address Line 2

City

County

Post Code

BILL PAYER DETAILS

Bill Payer Title

First Name

Surname

Home Phone

Work Phone

Mobile Phone

Same address as registered child?

Yes

Bill Payer Address

Address Line 1

Address Line 2

City

County

Post Code

PRIMARY CONTACT

Child Contact Title

First Name

Surname

Relationship to Child

Other Relationship to Child

Emergency Contact?

Yes

Parental Responsibilty

Yes

Authorised Pickup

Yes

Mobile Phone

Work Phone

Home Phone

Place of Work

Same address as child?

Yes

Primary Contact Address

Address Line 1

Address Line 2

City

County

Post Code

CONTACT 2

Contact 2 Title

First Name

Surname

Relationship to Child

Other Relationship to Child

Emergency Contact?

Yes

Parental Responsibilty

Yes

Authorised Pickup

Yes

Mobile Phone

Work Phone

Home Phone

Place of Work

Same address as child?

Yes

Contact 2 Address

Address Line 1

Address Line 2

City

County

Post Code

Add another contact?

Yes

CONTACT 3

Contact 3 Title

First Name

Surname

Relationship to Child

Other Relationship to Child

Emergency Contact?

Yes

Parental Responsibilty

Yes

Authorised Pickup

Yes

Mobile Phone

Work Phone

Home Phone

Place of Work

Same address as child?

Yes

Contact 3 Address

Address Line 1

Address Line 2

City

County

Post Code

DOCTORS DETAILS

Doctors Name

Practice Name

Phone Number

Emergency Number

Doctors Address

Address Line 1

Address Line 2

City

County

Post Code

CHILD QUESTIONNAIRE

Are there any special dietary requirements?

Yes

If so, please list them here:

Are there any special health considerations?

Yes

If so, please list them here:

EMERGENCY MEDICAL CONSENT

1.⁠ ⁠Routine First Aid - I give permission for my child to receive basic first aid treatment from a qualified member of staff if needed (e.g. cleaning and covering minor cuts, applying ice packs, comfort and reassurance).

Yes

2.⁠ ⁠Emergency Medical Treatment - In the event of a medical emergency, I give permission for Little Fireflies / Newton Lang staff to act in my child’s best interests, including seeking emergency medical treatment and calling the emergency services if required.

Yes

3.⁠ ⁠Understanding of Duty of Care - I understand that, regardless of consent, staff have a statutory duty of care to act to safeguard my child’s health and wellbeing in an emergency, and emergency services will be contacted if necessary.

Acknowledged

Are you happy for your child to play outside when its wet?

Yes

Additional info:

Do you give permission for your child to ride a scooter or bicycle without a helmet?

Yes

Additional info:

Are you happy for your child to watch a PG rated movie? (BBFC recommends age 8+)

Yes

Additional info:

Which of the following do you agree to your child being photographed during sessions? Tick to agree

Internal use, such as newsletters?

External use, such as website, facebook or flyer?

Used in public media, such as a local newspaper?

May we record your child’s image on video/webcam?

Yes

Additional info:

Are you happy for your child to take part in Forest School Activities?

Yes

Additional info:

Are you happy for your child to have sunscreen applied by staff?

Yes

Additional info:

Where you have not provided sunscreen labelled with your child’s name, are you happy for us to use the sunscreen provided by the nursery/ club?

Yes

Additional info:

ADDITIONAL SUPPORT INFORMATION

Is your child in receipt of Early Years Pupil Premium? (EYPP)

Yes

Unsure - I will check with the school

Additional Information

Does your child receive SEND support at school (e.g., SEN support plan, interventions, 1:1 support)?

Yes

Additional Information

Does your child have an Education, Health and Care Plan (EHCP)?

Yes

Additional Information

If Yes, do you give permission for the school to share relevant information from the EHCP with us, to support your child appropriately?

Yes

Additional Information

ABOUT YOUR CHILD

Special interests, likes:

Any dislikes:

Does your child like messy play?

Do you have any pets?

Your child’s position in family: e.g. Youngest of 2, has an older brother etc.

Anything else you would like to add?

PARENT / CARER DETAILS

I sign to confirm that all the above information is accurate to the best of my knowledge and agree to inform the Club if any details change.

A PDF of your submission will be emailed to you for your records.

Full Name of Parent / Carer

Date

Signature