Jack In The Box Nursery - Application Form To Use Nursery Facilities
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1JACK IN THE BOX NURSERY
APPLICATION TO USE NURSERY FACILITIES
Date of application:
Date that a place is required:
Name of applicant/s:
Relationship to child:
CHILD’S DETAILS
Who has parental responsibility for the child:
Child’s full name:
Date of birth/EDD:
Male/Female
First language
Who does the child live with:
Does your child have any additional needs such as a speech delay or hearing impairment, if so please provide full details:
Does your child have or are you currently awaiting a statement of special educational needs, if so please provide full details:
Has your child ever been referred to any of the following:
Speech Therapist
YES/NO
Paediatrician
YES/NO
Dietician
YES/NO
Occupational Therapist
YES/NO
Physiotherapist
YES/NO
Social Services
YES/NO
Audiologist
YES/NO
Psychologist
YES/NO
Domestic Violence Team
YES/NO
If yes please provide full details:
Does your child have any allergies, if so please provide full details:
PARENT/GUARDIAN’S DETAILS
1.Full name:
2. Full name:
Relationship to child:
Relationship to child:
Home address:
Home address:
Home tel no:
Home tel no:
Mobile tel no:
Mobile tel no:
E-Mail address:
E-Mail address:
Trust employed by (if applicable):
Trust employed by (if applicable):
Job title:
Job title:
Place of work:
Place of work:
Work tel no:
Work tel no:
First language:
First language:
SESSIONS/DAYS REQUIRED (please tick):
FULL DAY
Monday
Tuesday
Wednesday
Thursday
Friday
7.30am-5.30pm
7.45am-5.45pm
8.00am-6.00pm
AM SESSION
7.30-12.30
PM SESSION
1.00-6.00
Please note that the information you provide on this form regarding your child will not affect the offer of a place in the
nursery. It will simply help us to provide the most suitable care for your child.
Please return the completed application form to: Lee Owen, Nursery Manager, Jack In The Box Nursery, Upton
Hospital, Albert Street, Slough, SL1 2BJ. Telephone number: 01753 635480.
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