K2 - APPLICATION FOR CHILDCARE PLACES
Please ensure this form is completed in full in BLOCK CAPITALS. If you have difficulty completing
the form please let us know and we will be happy to help.
SECTION 1 – ABOUT YOU
This section must be completed by the parent/carer who has responsibility for the day care of the
child/ren who will take up a childcare place. Please complete boxes as appropriate:
Holiday
Term Time
Both
Ad Hoc
1.1 Your Name and Address
Surname ………………………………………….….… First Name(s) …………..……………………….
Address …………………….…………………………………………………………………………..……..
……………..……………………………………………………………………………………………………
Post Code ………………………………………….…. Home ……………...………...…………..………..
Email …………………………………..…………….… Mobile Tel No ……...…...............………………
1.2 Work
Name and Address of Employer ………….………………………………………………………………...
………………………………………………………………………………………………………………..…
Job Title/Department ………………………………… Tel No ………………………………….…………
Are you already in work? YES/NO If ‘No’, when do you plan to start work? ……………………...…
Can we contact you at work? YES/NO
1.3 If you are in or about to start education/training, complete this box.
Name and Address of University/College/Training Organisation ……………………….………………
……………………………………………………………………………………………………………..……
Course Title ………………………………….……… Length of Course ………….............…..…………
Start Date ……………………………..…………….. End Date ……………………..…………………….
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SECTION 2 – ABOUT YOUR CHILD (please complete a separate sheet for each child) Please
complete all details in this section. Please ask for a supplementary form if you require more space.
2.1 Child 1
Name………………………………..……………..……. Known As ………………………………….……
Does this child live with you at the address in Section 1? YES/NO If No please give the child’s
address below ….……………………………………………………..………………………………………
Date of Birth ……………..……………..………………. Age …………………… Gender: Male/Female
2.2 School
Which school does s/he attend (please tick)
St Peters
South Morningside
James Gillespie’s
Bruntsfield
Other (please give name of School) ………………………….…….… Class (P1 – P7) (S1-S2) ……
2.3 Health Information
Name of Family Doctor ……………………..……………………………………………………………….
Address of Medical Centre ……………………………………………………………………….…………
……………………………………………………….. Telephone ………………….………………..…......
Does your child have any allergies or special dietary requirements? YES/NO
If ‘Yes’ please give details ………………………………………………………………………………..…
Does your child have specific medical needs? YES/NO
Please describe and record any medication ………………………………………..…………………..…
2.4 Additional Support Needs (see attached) YES/NO
Please give details of any language and/or communication needs ……………….……………………
What, in your opinion, is the level of support and supervision required by your child?
…………………………………………………………………………………..………………………………
Are there any other people who support your child? E.g. Social Worker, Health Visitor, Speech
Therapist etc.
Name …………………………………………………….. Title ……………………………………………..
Address ………………………………………………………………………………………………………..
……………………………………………………………. Telephone ………………………………………
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SECTION 2 – ABOUT YOUR CHILD (please complete a separate sheet for each child) Please
complete all details in this section. Please ask for a supplementary form if you require more space.
2.1 Child 2
Name ……………………………………….………. Known As …………………..………………….……
Does this child live with you at the address in Section 1? YES/NO If No, please give the child’s
address below …………………………………...……………………………………………………………
Date of Birth ………………………………………… Age ………………..…… Gender: Male/Female
2.2 School
Which school does s/he attend (please tick)
St Peters
South Morningside
James Gillespie’s
Bruntsfield
Other (please give name of School) ………………………………….. Class (P1 – P7) (S1-S2) …..…
2.3 Health Information
Name of Family Doctor ……………………………………………………………………..……………….
Address of Medical Centre …………………………………………………...……………………………..
…………………………………………………………….…………. Telephone …………………………
Does your child have any allergies or special dietary requirements? YES/NO
If ‘Yes’ please give details ………………………..…………………………………………………………
Does your child have specific medical needs? YES/NO
Please describe and record any medication ………………………………………………………………
2.4 Additional Support Needs (see attached) YES/NO
Please give details of any language and/or communication needs …………….………………………
What, in your opinion, is the level of support and supervision required by your child?
…………………………………………………………………………………………………………………..
Are there any other people who support your child? E.g. Social Worker, Health Visitor, Speech
Therapist etc.
Name……………………………………………………….….. Title ………………………………………..
Address ……………………………………………..…..…………………………………………………….
……………………………………………………………….… Telephone …………………………………
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SECTION 2 – ABOUT YOUR CHILD (please complete a separate sheet for each child) Please
complete all details in this section. Please ask for a supplementary form if you require more space.
2.1 Child 3
Name ………………………………..……………………. Known As ……….……………………….……
Does this child live with you at the address in Section 1? YES/NO If No, please give the child’s
address below…………………………………………………………………………………………………
Date of Birth …………………………………..…………. Age …………..……… Gender: Male/Female
2.2 School
Which school does s/he attend (please tick)
St Peters
South Morningside
James Gillespie’s
Bruntsfield
Other (please give name of School) ………………………………..….. Class (P1 – P7) (S1-S2) ……
2.3 Health Information
Name of Family Doctor ……………………………..……………………………………………………….
Address of Medical Centre …………………………………………………………………….……………
…………………………………………………..………...….….. Telephone ……….…………………......
Does your child have any allergies or special dietary requirements? YES/NO
If ‘Yes’ please give details ………………………………………………………………………………..…
Does your child have specific medical needs? YES/NO
Please describe and record any medication …......…………….…………………………………………
2.4 Additional Support Needs (see attached) YES/NO
Please give details of any language and/or communication needs ……….……………………………
What, in your opinion, is the level of support and supervision required by your child?
…………………………………………………………………….……………………………………………
Are there any other people who support your child? E.g. Social Worker, Health Visitor, Speech
Therapist etc.
Name …………………………………………………….……….. Title……………………………………..
Address ………………………………………………………………………………………….…………….
……………………………………………………..……………….. Telephone ……………………………
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SECTION 3 – YOUR OUT OF SCHOOL CHILDCARE REQUIREMENTS
3.1 Child 1
Name ……………………………………………………………………………………..……………………
Requirements (please tick)
After School Provision (School Term)
Monday
Tuesday
Wednesday
Thursday
Friday
Please give usual time for picking up your child from our service ……………………….……………..
A separate booking form will be issued prior to all holiday periods.
3.2 Child 2
Name …………………………………………………………………………………..………………………
Requirements (please tick)
After School Provision (School Term)
Monday
Tuesday
Wednesday
Thursday
Friday
Please give usual time for picking up your child from our service …………….………………………..
A separate booking form will be issued prior to all holiday periods.
3.3 Child 3
Name ………………………………………………………………………………………………………..…
Requirements (please tick)
After School Provision (School Term)
Monday
Tuesday
Wednesday
Thursday
Friday
Please give usual time for picking up your child from our service ……………………….……………..
A separate booking form will be issued prior to all holiday periods.
We recognise that parents/carers often work irregular hours and may find it difficult to complete the
above information. However, if you require a guaranteed place for your child/children on any
particular day(s) it is essential you complete all your requirements.
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SECTION 4 – CARE AND SAFETY ARRANGEMENTS
4.1 Collecting your Child
Please state here the names of at least two people you authorise to collect your child when you
are unable to do so personally.
Name ……………………………...…………… Relationship to child …………………………………….
Name …………………………………...……… Relationship to child …………………………………….
Name ……………………………………...…… Relationship to child …………………………………….
Please note that we will not hand over your child to anyone other than people you have named
here and introduced to us. If we are in any doubt about the person picking up your child/ren we will
contact you. In emergency situations only we will accept person not nominated to collect your
child/ren, provided they know the password allocated by you and you have telephoned and
confirmed this with the Club Managers. Please ensure that he/she can provide identification.
Is there any person who is NOT permitted, by police or court order to have care of your child?
YES/NO
If ‘Yes’, please give that person’s name ………………………………... (Evidence must be provided)
4.2 Emergency Contact
If there is an emergency situation, e.g. your child is ill or does not arrive at the collection/meeting
point and we are unable to contact you at your work or college, please give any other numbers at
which you or any other person nominated by you can be contacted. Please provide at least 2.
Name ……………………………………………………. Tel No …………………………………….........
Mobile ………………………………………….
Name ………………………………………...…………. Tel No…………………….…………………......
Mobile ………………………………………….
Name ……………………………………………...……. Tel No ………………………………………......
Mobile ………………………………………….
For the safety of your child it is essential that this information is kept up to date at all times
– please inform us immediately of any changes to your circumstances.
4.3 Consent
We require consent for the following:
Day to day activities, including trips and outings
YES/NO
Medical help sought in cases of emergency
YES/NO
Photos – for use on publications/Promotional material’s YES/NO
Signature ………………………………………………
Details of the activities will be displayed in the playrooms. If you have any questions or
concerns, please talk to the play care staff.
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SECTION 5 – DECLARATION AND ADMINISTRATION
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I declare that the information I have given on this form is true and correct and I understand
that giving false information may lead to immediate withdrawal of the childcare place(s)
I agree to let you know immediately of any changes to the information provided on this form
I agree to let you have one week’s notice of any change to my after school childcare
provision and two weeks’ notice for cancelation of place
I have read and understood all the information in the pack relating to the services provided
by Kidscene
I accept the policies and practices, as specified in the information pack, under which
Kidscene operates
I accept the conditions attached to the childcare place, as specified in the information pack
I undertake to pay the required fees according to the fee structure and terms and conditions
of payment
Signature ……………………………….
Name (please print) ……………………..……….………..
Date ……………………………………..
How did you find about Kidscene?
Flyer
Primary Times
Website
Royal Blind magazine iSite
World of mouth
Facebook
Royal Blind e-newsletter
Families magazine
Internet search
Other Advertising (please Specify)………………………….
Twitter
I would like to receive further information about Royal Blind.
KIDSCENE, Royal Blind School, 43-45 Canaan Lane, Edinburgh EH10 4SG,
Tel.01031 446 3136, [email protected]
http://www.royalblind.org/kidscene
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SECTION 6 – FOR SENIOR MANAGER/OFFICE USE ONLY
Finance Account No
6.1 Allocation of Childcare Places – to be completed by CSM/FVM
Child 1 Name ……………………………………...………………………………………………………….
Monday
Tuesday
Wednesday
Thursday
Friday
Child 2 Name ……………………………………...………………………………………………………….
Monday
Tuesday
Wednesday
Thursday
Friday
Child 3 Name ……...………………………………………………………………………………………….
Monday
Tuesday
Wednesday
Thursday
Friday
Start Date …………………………………...…. School ……………….…………………………………..
Waiting List?
M
Tu
W
Th
F
(Please circle)
Child 1……………………………….
Child 2 ………………………………
Child 3……………………………….
6.2 Application Assessment
Assessment interview carried out by CSM/FVM
Signature ……………………………………………………..…………… Date …………………………..
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SECTION 7 – CHILD CARE VOUCHER / OTHER
For office use only
Title: …………… Forename: ……………………………. Surname: ……………………………………..
Address: ……………………………………………………………………………………………………….
……………………………………………………………… Postcode: ……………………………………..
Section 8 – Direct Debit
Instruction to your Bank or Building Society to pay Direct Debits
Payment Amount:
£
(Office use only)
Originator’s Reference
1st
Commencing M M
2 5 1 7 0 9
YY
Name & full address of your Bank/Building Society
Branch sort code:
To: The Manager________________________________
Bank or Building Society Account No:
Address_______________________________________
Postcode______________________________________
Name(s) of account holder(s)______________________
Instruction to your Bank or Building Society:
Please pay Royal Blind Direct Debits from the account detailed in
this instruction subject to the safeguards assured by the Direct
Debit Guarantee. I understand that this instruction may remain with
Royal Blind and, if so, details will be passed electronically to my
Bank/Building Society.
Signed
Date
Data Protection – Royal Blind is registered under Data Protection Act 1998, registration no. Z5603032. Information on the use of personal data by Royal Blind is
available from: PO Box 500, Gillespie Crescent, Edinburgh EH10 4HZ. Registered Charity No. SC017167. Royal Blinds values your support. We would like to keep you
up to date with information about our fundraising appeals and our charitable work.
Please tick here if you would prefer us not to contact you by post. Royal Blind will
not pass your details to non-associated companies but we may provide your data to those associated organisations providing related products and services that may be
of interest to you. These Organisations may contact you by post or by telephone concerning these offers. If you do not wish these organisations to contact you please tick
here.
The Direct Debit Guarantee This Guarantee is offered by all banks and building societies that accept instructions to pay Direct Debits. If there are any
changes to the amount, date or frequency of your Direct Debit Royal Blind will notify you ten working days in advance of your account being debited or as otherwise
agreed. If you request Royal Blind to collect a payment, confirmation of the amount and date will be given to you at the time of the request. If an error is made in the
payment of your Direct Debit, by Royal Blind or your bank or building society, you are entitled to a full and immediate refund of the amount paid from your bank or
building society. If you receive a refund you are not entitled to, you must pay it back when Royal Blind asks you to. You can cancel a Direct Debit at any time by simply
contacting your bank or building society. Written confirmation may be required. Please also notify us.
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