Application form Nannies Nursery: Child's Details:First Name Last Name Birthdate SexBoyGirlStreet Address City ZIP / Postal Code Home phone numberBSNApplicant parent:First name Last Name Phone NumberWork phone numberEmail Address BSNSecond parent:First name Last Name Street AddressCityZIP / Postal CodeBSNWho has parental responsibility?:NameNameAre there any contact restrictions(if yes please give details below):YesNoDetails:Time table:Start DateCheckboxMondayTuesdayWednesdayThursdayFridaySaturdaySundaySpecify time table0 / 180Doctor's Details:Doctor's nameDoctor's last nameStreet AddressCityZIP / Postal CodeCountrySelect countryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgia, CountryGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabweHealth visitor's namePhone NumberMedical details:Does you child have any medical problems that we should be made aware of? Please give details belowDoes your child have any allergies that we should be made aware of? Please give details belowIs your child on any long term medication that we should be made aware of ? Please give details belowDoes your child have any special dietary requirements? e.g Vegetarian. Please give details belowOther Emergency Contacts:NamePhoneRelationship to the childNamePhoneRelationship to the childPermissions:Do you give the nursery permission to take photographs of your child for development files?YesNoDo you give the nursery permission to take photographs of your child for promotional purposes?YesNoDo you give the nursery permission to use sunscreen (factor 50)?YesNoDo you give the nursery permission to administer first aid?YesNoDo you give the nursery permission to take your child on outings to the park etc?YesNoCollection Arrangements Who is autorised to collect your child from nursery other than parents? Your child will only be allowed to leave nursery with people listed here.NameRelationship to child:Any more authorizations?YesNameRelationship to childAs an extra precaution you may use a password. Anyone collecting your child should be made aware of this.Child's Background :What is the first language spoken at home?Is there any other language spoken at home?Bank account details:Account holderBank nameBank code (SWIFT / BIC)IBANSend Application
