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Please print out this form and fill it in. It contains important information that we need to know in respect to your child's safety and health.
Name of Child:
Date of Birth:

Mothers Name:
Fathers Name:
 
Home Address:



   
E-mail Address:
 
Home Telephone No:
Mobile No: 
Mothers Work No: 
Fathers Work No: 
   
Name of School: 
School Contact Name: 
School Telephone No: 
   
Emergency Contact Name:
Emergency Contact Telephone No: 
2nd Emergency Contact name: 
2nd Emergency Contact No: 
   
Has your child been fully immunised against:    
Diphtheria  
Whooping Cough  
Tetanus  
Polio  
Measles  
Mumps  
Rubella  
Hib Meningitis  
Chickenpox  
Any other important information:



Date: