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HOLIDAY PLAY SCHEME REGISTRATION FORM
By completing this form you register your interest in a place at
Coin Street Holiday Play Scheme programme. You are not guaranteed a
place until you have specifically been contacted and notified.
Date (DD/MM/YY):
Time (HH/MM):
CHILD DETAILS
First name:
Last name:
Date of birth (DD/MM/YY):
Current age:
Gender (please circle):
Male Female
Ethnicity* (Please circle):
White
British
Greek
Cypriot
White
Irish
Turkish
White
Irish
Traveller
White
Western
Europe
White
Eastern
Europe
White
Other
Turkish
Cypriot
Black
Caribbean
Kosovan
Greek
Mixed
White and
African
Mixed
Other
Other Black
African
Other Asian
Any other
Black
background
Indian
Latin/South/Central
Nigerian
Pakistani
Prefer not to say
Gypsy/Roma
Somali
Bangladeshi
Other (please
specify):
Mixed
White and
Black
African
Mixed
White and
Caribbean
Sierra
Leonian
Chinese
Ghanaian
Vietnamese
School attending:
Postcode:
Coin Street neighbourhood centre
108 Stamford Street, South Bank, London SE1 9PH
020 7021 1600 [email protected]
www.coinstreet.org
Kurdish
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*Our Children's Centre funding requires us to provide statistical
information about the ethnic origin of children using our services.
We will not use this data for any other purposes.
All personal information given on this form will be held and used in
accordance with the Data Protection Ac t 1998.
MOTHER’S/GUARDIAN’S DETAILS
Title (please circle):
Miss Mr
Mrs
Ms
Other (please
specify):
First name:
Last name:
Address:
Post code:
Home telephone:
Work telephone:
Mobile:
E-mail:
Relationship to child/children:
Borough (please circle):
Lambeth
Southwark
Other (please
Mrs
Other (please
specify):
FATHER’S/GUARDIAN’S DETAILS
Title (please circle):
Miss Mr
Ms
specify):
First name:
Last name:
Address:
Post code:
Home telephone:
Work telephone:
Mobile:
Coin Street neighbourhood centre
108 Stamford Street, South Bank, London SE1 9PH
020 7021 1600 [email protected]
www.coinstreet.org
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E-mail:
Relationship to child/children:
Borough (please circle):
Lambeth
Southwark
Other (please
specify):
EMERGENCY CONTACTS (this cannot be any of the persons
names above)
Emergency contact 1
Name:
Phone number:
Relationship to child:
NON-CONTACT (anyone who is NOT allowed to collect or
have contact with the child)
Name:
Phone number:
Relationship to child:
If you have named a person as non-contact, please ensure that this
is discussed with the Senior Administrator. You will be asked to
share the relevant paperwork where appropriate.
HEALTH INFORMATION
Please confirm any diagnosed or suspected health concerns your child
may have, such as asthma or diabetes. Together we will devise a plan
to ensure your child receives appropriate care.
Does your child have any allergies? (Please circle):
If yes, please specify
Coin Street neighbourhood centre
108 Stamford Street, South Bank, London SE1 9PH
020 7021 1600 [email protected]
www.coinstreet.org
Yes
No
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Does your child have any dietary requirements? (Please circle):
Yes
No
If yes, please specify
Does your child require any special skin care? (Please circle):
Yes
No
If yes, please specify
Does your child have any distinguishing marks, such as Mongolian
Blue Spot?
(Please circle):
Yes
No
If yes, please specify
Please note we do not administer any medication unless it has been
specifically prescribed and the relevant forms have been signed.
Terms and conditions of Holiday Play Scheme placement
In these terms and conditions, "Holiday Play Scheme", and "we" and
"our" means Coin Street
Centre Trust, situated at Coin Street neighbourhood centre.
"Parents" or "you" means the parents or guardians or the person
responsible for any child registered at Holiday Play Scheme; and
"children" or "child" means any child that has been registered at
Holiday Play Scheme.
In order to register your child with Holiday Play Scheme parents
must fill in the registration form, (available on request). Please
note that a registration fee is not required and children registered
with the holiday play schemes automatically stay on our register
each term. Holiday play scheme children remain registered but do
Coin Street neighbourhood centre
108 Stamford Street, South Bank, London SE1 9PH
020 7021 1600 [email protected]
www.coinstreet.org
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need to book for each play scheme by completing a form and make all
payments in advance of the booking.
Registration fee
Once CSOSC has notified you that your child has secured a booking,
payment must be made in full before the start of each holiday club
period. Payment is required and will not be refunded irrespective of
attendance including absence due to illness, family holidays or
preference, however caused as this has prevented another child
attending.
Cheques can be made payable to 'Coin Street Centre Trust' or 'CSCT'.
Please inform us as soon as possible if your child is going to be
absent and of any infectious illness so we can warn others. Please
keep your child at home if they have been sick, had diarrhoea or
have conjunctivitis for at least 24 hours after the last bout or
until medication has been administered for at least 24 hours
depending on the illness - please contact the office for specific
instructions. We reserve the right to send home any child if such an
action is deemed to be in the best interests of that child or the
other children. The registration form asks for contact details in
case of accident/illness, parents/carers must ensure that we know of
any change in marital status, address or telephone/mobile numbers
this is for your child's emotional wellbeing and in case we have to
contact you in an emergency and call social services.
Late drop offs and collections
Parents must ensure that children are dropped off by 9:30am unless
otherwise advised, as this is often the time children leave for
trips. If you are not in by this time we will give you directions as
to where to find the group when it is possible to join them. We will
not offer other forms of childcare when children are late.
Please note that it is important for the children and for our staff
that children are collected promptly. We appreciate that delays can
sometimes be unavoidable, but to cover our costs we do reserve the
right to charge £5.00 per 10 minutes caring for children when
parents are late. If we are unable to contact a parent by 6.30pm we
will follow our non collection of child policy which is displayed in
the settings. If a child is repeatedly collected late than there is
a risk of forfeiting their place. This decision will be at the
discretion of Holiday Play Scheme.
In the event of any fees remaining unpaid, parents breaching any of
these terms and conditions or we deem this action to be necessary in
the interests of the other children or of Holiday Play Scheme, we
reserve the right to suspend or terminate a child's place.
Upon registration of a child at Holiday Play Scheme, Holiday Play
Scheme and the staff employed will act in Loco Parentis for the
duration of the time that the child is in our care, both on and off
the premises, until a parent or chosen representative collects the
Coin Street neighbourhood centre
108 Stamford Street, South Bank, London SE1 9PH
020 7021 1600 [email protected]
www.coinstreet.org
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child. In the case of any illness, accident or emergency, Holiday
Play Scheme shall have the right to take such actions as are deemed
appropriate, including hospitalisation if necessary even if the
parents have not yet been informed.
I confirm that I have read, understood and agree to the above terms
and conditions. I certify that the information stated is true and
correct to the best of my knowledge. I understand that further
enquiries may be made at the discretion of the Coin Street family &
children's centre. (Please tick to confirm)
PERMISSIONS LIST
Consent A: Application of sun cream
I hereby give permission for the application of sun cream
supplied from home.
THIS MUST BE CLEARLY LABLED.
Consent B: Visits to local places of interest
I hereby give permission for our child/children to be taken on
planned outings organised and approved by Coin Street family &
children's centre.
Consent C: Portfolio photography
I hereby give permission for our child/children's photo to be
taken and displayed/used within the children centre.
Consent D: Promotional photography
I hereby give permission for our child/children's photo to be
taken as stated in the questionnaire and displayed/used for
promotional purposes if needed.
Consent E: Face paint
I hereby give permission for our child/children's to have face
paints applied.
Consent F: Travel
I hereby give permission for our child/children's to travel by
public transport/coach.
KEEP UP TO DATE
Coin Street neighbourhood centre
108 Stamford Street, South Bank, London SE1 9PH
020 7021 1600 [email protected]
www.coinstreet.org
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I would like to sign up to the Coin Street e-list to keep up to date
with free and local events and activities (please circle):
Yes
No
IMPORTANT – PLEASE READ THE FOLLOWING BEFORE SUBMITTING THIS
FORM
Yes I give consent for my child/children to be
photographed/filmed for education & information purposes
Yes I give consent for my child/children to be
photographed/filmed for promotional purposes
No, I do not consent for my child/children to be
photographed/filmed
I confirm that I have legal responsibility for all children
listed on this form and have filled in this form with
information correct to the best of my knowledge (please tick
to confirm)
PLEASE NOTE: Once your booking has been confirmed, you cannot cancel
or make changes to the requested dates of the programme.
Please post or deliver your booking form to the address below for
the attention of Nursery Administrator, or email
[email protected]
Coin Street neighbourhood centre
108 Stamford Street, South Bank, London SE1 9PH
020 7021 1600 [email protected]
www.coinstreet.org