Key Information Data Capture "*" indicates required fields 1Your details2Child's details 3Emergency Contacts4Health & Diet5Photo consent Who's filling in this form?* First Last Relationship*MotherFatherStep-MotherStep-FatherNannySiblingAuntUncleNeighbourGrandparentGuardianFamily friendAu PairPersonal/Executive Assistant Child's name* First Last Date of birth DD slash MM slash YYYY Year group*PreschoolReceptionForm 1Form 2Form 3Form 4Form 5Form 6 Emergency Contact InformationEmergency Contact 1: Name* First Last Relationship*MotherFatherStep-MotherStep-FatherNannySiblingAuntUncleNeighbourGrandparentGuardianFamily friendAu PairPersonal/Executive AssistantEmail* Phone*NotesEmergency Contact 2: Name* First Last Relationship*MotherFatherStep-MotherStep-FatherNannySiblingAuntUncleNeighbourGrandparentGuardianFamily friendAu PairPersonal/Executive AssistantEmail* Phone*Notes Health and DietImmunisations* Diphtheria Tetanus Polio Whooping cough MMR x 2 Meningitis C None of the above Select AllPlease select all immunisations your child has had. If your child has not had one of these immunisations or completed the course (if relevant), please let the school office know if and when your child is immunised.Immunisation Date: Diptheria DD slash MM slash YYYY Immunisation Date: Tetanus DD slash MM slash YYYY Immunisation Date: Polio DD slash MM slash YYYY Immunisation Date: Whooping Cough DD slash MM slash YYYY Immunisation Date: MMR (First dose) DD slash MM slash YYYY Immunisation Date: MMR (Second dose) DD slash MM slash YYYY Immunisation Date: Meningitis C DD slash MM slash YYYY Please tick if your child has had any of the following:* None of the below Mumps Measles German measles Chicken pox Whooping cough Scarlet Fever Does your child suffer from any of the following? If the answer to any of the below is Yes, please select and give full details below.* None of the below Asthma Hay fever Eczema Allergies (food, bites, antibiotics, anti-histamine, suncream) Epilepsy / fits / convulsions Serious illness or operation Diabetes DetailsDo you give consent for your child to be given prescribed medication by staff at Bassett House, eg: inhalers if required?* Yes No Is your child allergic to plasters or antiseptic wipes?* Yes No (Unless the school has been informed that your child is allergic to either plasters or antiseptics, if an accident should occur the wound will be cleaned with water and/or an antiseptic wipe and a plaster applied if necessary.) Has your child been prescribed an epipen?* Yes No Please note that the school requires two epipens for any child for whom an epipen has been prescribed – one to be kept in the school office and the other to be kept in the child’s classroom.Please note below any current serious health conditions of which the school should be aware.Does your child adhere to a specific diet for health or religious beliefs eg. vegetarian, vegan, halal, kosher etc?* Yes No Does your child have any allergies, or medical or other needs in terms of their diet?* Yes No If you answered yes, please give details below.If so, please state them here. Any such dietary requirement must have been recommended by a medical doctor or be due to religion or belief (as protected by law). Photo consentI consent to my child being featured in photo and video content to be shared on the school's website, social media and in marketing materials for Bassett House and Dukes Education Group during my child's time at the school and for up to two years after leaving.* I consent I do not consent
