THE SPA AT BECKENHAM CHILD INFORMATION Name: Surname: Known as: Ethnicity: Date of Birth: Age: Current Address: Language spoken: Is children’s Social Care currently involved with your child? YES / NO If yes, is your child on a Child Protection Plan? YES / NO Name: Address: 1st Contact number: 2nd Contact number: Email address: 1st contact 2nd contact Name: Contact number: (Crèche Only) In order to maintain the Health and Safety of all children in our care it would be useful to have this information. Please confirm your child has received the following vaccinations Diphtheria x 3 Tetanus x 3 Whooping x 3 Polio x 3 Meningitis Hib Meningitis x 3 Measles Mumps Rubella List any medical conditions or pre existing injuries ( Including allergies) For allergies please also complete an allergy management plan Does your child need to take medication whilst attending the setting? (If Yes, please complete the health management plan and the permission to YES / NO administer medication form) Doctors name: Doctors Address: Contact number: Does your have any additional needs? YES / NO (If yes, please complete an additional needs form) Are there any foods / drinks your child is not allowed to consume? If YES, Please list YES / NO below
SPA AT BECKENHAM Name: Surname: Known as: Ethnicity: Date of Birth: Age: Current Address: Language spoken: Is children’s Social Care currently involved with your child? YES / NO If yes, is your child on a Child Protection Plan? YES / NO Name: Address: 1st Contact number: 2nd Contact number: Email address: 1st contact 2nd contact Name: Contact number: (Crèche Only) In order to maintain the Health and Safety of all children in our care it would be useful to have this information. Please confirm your child has received the following vaccinations Diphtheria x 3 Tetanus x 3 Whooping x 3 Polio x 3 Meningitis Hib Meningitis x 3 Measles Mumps Rubella List any medical conditions or pre existing injuries ( Including allergies) For allergies please also complete an allergy management plan Does your child need to take medication whilst attending the setting? (If Yes, please complete the health management plan and the permission to administer medication form) YES / NO Doctors name: Doctors Address: Contact number: Does your have any additional needs? (If yes, please complete an additional needs form) YES / NO Are there any foods / drinks your child is not allowed to consume? If YES, Please list below YES / NO CHILD INFORMATION THE