Confidential Child Record — Molesey Day Nursery

Child Information

Child's name

First Name

Last Name

Date of Birth

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Languages Spoken at Home

Ethnic Origin

Name of GP

GP Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

GP Phone Number

Child's Health Records

Immunisation Records

Please check all that apply. PCV = Pneumococcal Disease HIB = Influenza MenB = Meningococcal

Under 12 months: Men B x2/Rotavirus x2 /PCV/ 6-in-1 vaccine (diphtheria, hepatitis B, Hib (Haemophilus influenzae type b), polio, tetanus, whooping cough)

1 year: Hib/Men C/ MMR x1 /PCV booster/ Men B x1

Over 3: MMR x1 / 4 IN 1 preschool booster (diphtheria, tetanus, whooping cough, polio)

Infectious Diseases Contracted

( Whooping cough / Mumps / Scarlet Fever / Chicken Pox / Diphtheria / German Measles / Measles / COVID / Other )

Illness, Accidents, Disability Records, Medical Operations

Provide details if applicable

Allergies, Ongoing Treatment, Medication, Special Conditions / Therapy

Provide details if applicable

Parental/Guardian Information

Name of Parent/Guardian 1

First Name

Last Name

Parent/Guardian 1 Email

Parent/Guardian 1 Work Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian 1 Phone Number

Name of Parent/Guardian 2

First Name

Last Name

Parent/Guardian 2 Email

Parent/Guardian 2 Work Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian 2 Phone Number

Who has parental responsibility? (usually both parents - please confirm)

Additional Contacts

Additional Contact 1

First Name

Last Name

Relationship to Child

Additional Contact 1 Phone Number

Additional Contact 2

First Name

Last Name

Relationship to Child

Additional Contact 2 Phone Number

Confirmation

I confirm all the above information is correct and will contact the Nursery when any information needs to be updated