Author: Summera zafar

REGISTRATION FORM

Please complete and return to:
Bishop Bevan Hall, Lion Street, Brecon, LD3 7HY
Tel: 07498025306/07930749835
Email: admin@willowsbrecon.co.uk

CHILDS DETAILS Boy Girl Gender Unknown
Child’s full name: ___________________________________________________________________________
Known as: __________________________________ Date of Birth: _________________________________
Birth certificate number: ______________________ Ethnic origin: _________________________________
(we need to see a copy please) (broad ethnic group not place of birth)
First language: _______________________________ Other languages: ______________________________

Please indicate your child’s attendance pattern required and enclose the registration fee with your form
Start date: ________________________

Days	Morning / (8.00-13.00)	Afternoon / (13.00-18.00)	School Day / (8.30-15.30)	Full Day / (8.00-18.00)	After School Club / (15.00-18.00
Monday
Tuesday
Wednesday
Thursday
Friday

MEDICAL DETAILS
Doctor’s name: ______________________________
Practice address: _____________________________
___________________________________________
Telephone number: ___________________________
Health visitor: _______________________________
Telephone number: ___________________________
Social worker: _______________________________
Telephone number: __________________________
Are all immunisations up to date: Yes No
If no state exceptions: _________________________
______________________________________________________________________________________

Any special medical needs (please detail): __________
__________________________________________________________________________________________Any special dietary requirements (please detail):
__________________________________________________________________________________________
Any allergies: (please detail): _____________________