CRANNOG NA LEANAÍSTEINER KINDERGARTENAPPLICATION FORM

Name of Child Date of Birth Sex: Male / FemaleAge at Entry PPS No. ______________________Child’s Full Address_____________________________________________________________________________________________________________________________Name of Mother __________________________________________________________Address (if different from child) _______________________________________________________________________________________________________________________Telephone ___

Home Work MobileEmail Address __________________________________________________________Name of Father _________________________________________________________Address (if different from child) ____________________________________________________________________________________________________________________Telephone: _______________(Home) ____________________(Work) _________________(Mobile)Who will be financially responsible for the fees?Name Signature Number

____________________________________________________________________________________________________________________________________________

Names and ages of brothers and sisters

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Who, other than parents is authorised to collect your child from Kindergarten? Name Telephone Mobile

PLEASE INFORM THE KINDERGARTEN TEACHERS IMMEDIATELY OF ANY CHANGES IN ADDRESS, TELEPHONE NUMBERS, DOCTORS DETAILS ETC

Intended start date: ________________________________________________________________

How many days would you like your child to attend Kindergarten? ___________________

Please circle preferred Session and days: Mornings Afternoons

Monday Tuesday Wednesday Thursday Friday

I give permission for my child to go on outings with staff: Yes ☐ No ☐(Regular outings are within the boundaries of Duffcarraig Camphill Community)

Signed: _________________________________________________________________________Name (Please Print): ______________________________________________________________

Date: ___________________________________________________________________________

Relationship to Child: ___________________________________________________________________

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I undertake that as part of my commitment as a parent/guardian of a child/ren in Crannóg Na Leanaí Steiner

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Please ensure that you enclose with your application:A recent photograph of your child ☐Completed photographic consent form ☐Completed medical consent form ☐Completed vaccination information form ☐Completed GDPR consent form ☐

Child Profile

Can you describe your pregnancy, delivery and birth of child (if applicable):__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

When did your child start:Teething: ____________________________ Crawling: ____________________________Standing: ____________________________ Walking: ____________________________Talking: ____________________________Is there anything else you would like to say about these events?______________________________________________________________________________________________________________________________________________________

Can you describe your child’s development generally in the first few years (socially, emotionally, physically):____________________________________________________________________________________________________________________________________________________

Has your child had any formal socialising e.g. playgroup/crèche/kindergarten?_________________________________________________________________________If yes, how was his/her experience?__________________________________________________________________________How much time each week (if any) does your child spend:

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Watching television: _______________________________________________________ Watching DVDs___________________________________________________________Playing computer games: ___________________________________________________What is your child’s first language? ______________________________________

MEDICAL INFORMATION

Family Doctor (Name, Address, Telephone Number): Who may be contacted in emergency if parents not available?

Name Telephone Mobile

Name Telephone Mobile

Name Telephone Mobile

Has your child had any major accidents or operations? If so, please give details: Has your child at any time suffered from any allergy ( e.g. hay fever, insect stings, food, medication)

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Please indicate if your child has any of the following conditions:Bedwetting: Diabetes: Asthma:

Epilepsy:

If yes, please indicate any relevant medical treatment required:

Has he/she had any of the following illnesses? (If so, please indicate when)Chickenpox: Measles: Mumps: German Measles:Tuberculosis: Polio: Whooping Cough:

Scarlet Fever:Does your child have any other serious illnesses? If so, please give details:

Has your child ever been referred to child psychiatrist, educational psychologist or paediatrician? Please give details: ______________________________________________________________

Does your child have any disabilities? Please give details: Does your child have any special dietary requirements? Is there anything else we should know about your child?

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CRANNÓG NA LEANAÍ STEINER KINDERGARTEN Medical Consent Form

Medical EmergenciesIn the event of a medical emergency the Kindergarten staff will contact parents/emergency contact person. If it is not possible to contact a parent/emergency contact person, then the Kindergarten staff must have received prior written consent from parents in order for them to seek medical attention for any child. In this situation a doctor/ambulance will be called and staff will accompany a child if a parent/guardian is not available.

I ____________________________________________ give my consent for Crannóg Na Leanaí Kindergarten staff to seek emergency medical treatment where necessary for: _________________________________________________________(child).

In the event of such an emergency occurring, I will be notified of same.

Minor InjuriesIn the case of minor injuries these will be treated locally in the Kindergarten. Consent is also requested for the staff to apply arnica and/or calendula cream in the case of minor bumps, bruises, cuts or grazes.

I give my consent for staff to apply Arnica Cream and Calendula Ointment topically if needed:

Arnica Cream for bumps and bruises: Yes ☐ No ☐Calendula Ointment for cuts or grazes: Yes ☐ No ☐

In general, there is no administration of medicines in the Kindergarten.

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GP Name & Address: _____________________________________________________________

_____________________________________________________________GP Telephone No.: _____________________________________________________________

Signed: ____________________________________ (Parent)

Date: _____________________________________Epipens/Auto-InjectorsIf a child has a serious allergy that requires an Epipen/Auto-Injector to be kept at the Kindergarten for them, it is a requirement that the parent provides training for the Kindergarten staff in the safe use of the Epipen/Auto-Injector for the child.

I ________________________________ (Parent) have given training to the following staff members in the use of the Epipen/Auto-Injector for ____________________________(Child) and I give them permission to administer same if needed: ______________________________________________ (Staff) Yes ☐ No ☐______________________________________________ (Staff) Yes ☐ No ☐______________________________________________ (Staff) Yes ☐ No ☐______________________________________________ (Staff) Yes ☐ No ☐

Instructions Given - How to Use Epipen/Auto-Injector: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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____________________________________________________________________________________________________________________________________________________________________

Parent Signature: _______________________________ Date: ______________________Staff Signature: ________________________________ Date: ______________________Staff Signature: ________________________________ Date: ______________________Staff Signature: ________________________________ Date: ______________________Staff Signature: ________________________________ Date: _____________________

CRANNOG NA LEANAÍ STEINER KINDERGARTEN Photographic Consent Form

We have a Kindergarten website and Facebook account which we update regularly and sometimes

we may require photographs for the promotion of the Kindergarten. We would like your permission

to use photographs that we may have of your child engaged in Kindergarten activities for this

purpose. The photographs will not show your child’s face unless you have specifically given us

permission to use that particular image. We also have a parents WhatsApp group which we may

sometimes share photographs on; these photos may sometimes show your child’s face.

I ______________________________________ (name of parent/ guardian)

give my consent for Crannóg Na Leanaí Kindergarten

to photograph______________________________ (name of child) Yes ☐ No ☐

I give my consent for my child’s photograph to be used for the following:

Website: Yes ☐ No ☐Facebook: Yes ☐ No ☐WhatsApp Parent Group: Yes ☐ No ☐

Signed: _____________________________________

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Date: ______________________

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CRANNOG NA LEANAÍ STEINER KINDERGARTEN Vaccination Information Form

Name of Child: __________________________________________________Date of Birth: ___________________________________________________Home Address: __________________________________________________________________________________________________________________

Vaccination No Yes Date:

BCG (TB)

6 in 1 + PCV

6 in 1 + Men C

6 in 1 + Men C + PCV

MMR + PCV

Men C + Hib

School 4 in 1 + MMR

BCG = Bacille Calmette-Guérin6 in 1 = Diphtheria, Tetanus, Pertussis, Polio, Haemophilus influenzae b, Hepatitis BPCV = Pneumococcal Conjugate VaccineMen C = Meningococcal C

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MMR = Measles, Mumps, RubellaHib = Haemophilus influenzae b4 in 1 = Diphtheria, Pertussis, Polio, TetanusTd = Tetanus, Diphtheria

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+

Steiner Inspired Kindergarten

GDPR PARENTAL CONSENT FORM

I, _______________________________, confirm that _____________________________ is below

the age of 16 years old and I am hereby consenting on his/her behalf that Crannóg Na Leanaí can

process personal data and the sensitive personal data relating to for

observational purposes and in order to apply for funding on your behalf.

This data pertains to photographs/medical records/psychological reports/safety orders/outings etc.

This record of consent will be saved in your child’s file and retained for a period of seven years after

your child has left our service. I am aware that I may withdraw the consent of __________________

at any time by using the “PARENTAL CONSENT WITHDRAWAL FORM.”

Signed by Parent/Representative/Legal Guardian,

Signature: _______________________________________

Date: ___________________________________________

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