Anouska’s Lodge, The Grove – Coronavirus COVID-19 Information

Child's Name

Child's current address

Please provide parent/carer details responsible for your child, contactable in the event of an emergency:

Parent/Carer 1's Details

Name

Relationship to child

Contact telephone number

Alternative contact number

E-mail

Parent/Carer 2's Details

Name

Relationship to child

Contact telephone number

Alternative contact number

E-mail

In an emergency and we cannot speak immediately with either of the above parents/carers on the telephone, please provide two additional emergency contacts that we may call as responsible carers:

Additional Emergency Contact 1's Details

Name

Telephone number

Additional Emergency Contact 2's Details

Name

Telephone number

Password

To be used at collection by additional emergency contact

Dietary Requirements *

Please provide your child’s latest dietary requirements inclusive of allergies, medical intolerances, vegetarian or no sweet desserts:

Medical Requirements *

Please provide your child’s latest medical requirements including symptoms and treatment in case of an emergency:

Sleep Information *

Please tick the relevant boxes below:

My child does not require a sleep at nursery.

My child has a restricted sleep at nursery.

They require minutes sleep

My child has no restrictions and can sleep as necessary.

My child has a dummy at sleep times.

My child has a comforter/blanket at sleep times.

Toilet/Potty Training *

My child wears nappies.

My child is potty training and I have provided additional clothing.

My child is toilet training and I have provided additional clothing.

My child requires a nappy at sleep time only.

My child is fully toilet trained.

Declarations

You will be asked to sign below in person when you next attend after submitting this form, please now click Submit at the bottom of this page.

I understand the required procedure for drop-off and collection of my child from the setting during the Coronavirus pandemic

Signed .............................. Date .........................

I understand that if my child is showing any signs or symptoms of Coronavirus, they will be collected by a responsible carer as soon as possible and will self-isolate following government guidelines unless testing shows a negative result.

Signed .............................. Date .........................

I understand that if we or anyone in our household shows signs of Coronavirus, we shall notify the setting and self-isolate according to the government guidelines.

Signed .............................. Date .........................

Receive a copy of this form via email?

Yes