Preschool Registration Form Page 3

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Start Date:
Preferred Start Date:
Age of Child at Start Date:
Previous Care:
Medical Details:
Doctors Name:
Surgery / Practice:
Address:
Post Code:
Tel Number:
Immunisations and illnesses:
Please tick the boxes below to indicate if your child has been immunised against and/or suffered
from any of the illnesses listed.
Illnesses
Immunised
Suffered From
Diphtheria
Tetanus
Whooping Cough
Polio
HiB
Meningitis C
MMR
Measles
Mumps
Rubella
Pneumococcal
BCG
Chicken Pox
Scarlet Fever
Any Other?
Knaphill Pre-School | Brookwood Country Park Pavilion | Off Redding Way | Knaphill | GU21 2QT
Tel 07914 707802 | dawn@knaphillpreschool.co.uk |

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