Application Form for NurseryHead Teacher: Faisal Khan

Early Years Manager: Zameed Akhtar

FOR ADMINISTRATIVE USE ONLY

Full Name of Child: …………………………………………………………………

Date Application received: ……..............

Copy of Birth Certificate attached: EYDCP Declaration signed:

Eligible for EYPP:

Date Acknowledgement Letter sent: ............... Date of Home Visit: .........................

Date of Taster Session: ……...................... Date of Admission: ……………....

Action Taken: 1) Home visit 2) Admitted 3) Waiting List 4) Apologised

Admission Number: If on waiting list, date of proposed admission: ………………………………........

Days & Hours required: ......................................................................................

Date of Termination: ............................ Head Teachers Signature:

Routine question………………………… ……………………………………….

FOLLOW US ON FACEBOOK – ‘FRIENDS OF OAKWOOD’COMPANY REGISTERED IN ENGLAND AND WALES. REGISTERED NUMBER 6410625

OFSTED URN. 135539 - DCSF NO. 821/6011 - CHARITY NO. 1123924

PERSONAL DETAILSFull Name of Child: …………………………………………………………………

Date of Birth: …………………………… Gender: Boy / Girl (please circle)

Age of Child on 1st September 20__: …………..

Address: ……………………………………………………………………………...…………………………………………………………………………………………..Town: …………………………………….. Postcode: ……………………...

Home Telephone: ……………………... (with STD)

Nationality: ………………………………. Place of Birth: …………………Religion: …………………………………. No. of children in family: ……..Legal Status/ Visa Status / Immigration Status: ………………………………......

Full Name of Father / Guardian: ………………………………………………….

Country of Origin: …………………………….. E-mail: ....................................National Insurance Number: ………………… Date of Birth: ………………….Legal Status/ Visa Status / Immigration Status: ………………………………......

Address with postcode: ………………………………………………………………………………………………………………………………………………………..

Home / Work: …………………... (with STD) Mobile: ....................................

Full Name of Mother / Guardian: …………………………………………………

Country of Origin: …………………………….. E-mail: ....................................National Insurance Number: ………………… Date of Birth: ………………….Legal Status/ Visa Status / Immigration Status: ………………………………......Address with postcode: ………………………………………………………………………………………………………………………………………………………..

Home / Work: …………………... (with STD) Mobile: ....................................

Who does the child normally live with? ..............................................................Who has legal contact and parental responsibility for the child? .......................

INFORMATION IN CASE OF EMERGENCYPlace where Parents / Guardians can be contacted during the day

Full Name of Parent / Guardian: ………………………………………………….Workplace Full Address: …………………………………………………………….…………………………………………… Postcode: ……………………...Work Telephone: …………………....... (with STD)

Please provide details of someone whom we could contact (other than the Parent/Guardian) should your child become ill and we cannot contact you.

Full Name: ……………………………. Telephone: …………………….Address: ……………………………………………………………………………....…………………………………………… Postcode: ……………………...Relationship to Child? ……………...................................................................

Please provide details of someone whom we could contact (other than the Parent/Guardian) should your child become ill and we cannot contact you.

Full Name: ……………………………. Telephone: …………………….Address: ……………………………………………………………………………....…………………………………………… Postcode: ……………………...Relationship to Child? ……………..................................................................

ABOUT YOUR CHILDWhat is your child’s first language at home?: ..............................................Does your child speak English fluently? Yes No

Names of any siblings attending Oakwood Primary School: ……………………………………………

Does your child have any learning difficulties or special needs such as: ADHD, Speech and language, Autism, Yes No

If yes, please describe: …………………………………………............................. …………………………………………………………………………………………..…………………………………………………………………………………………..

Please use the space below to tell us any other additional information about your child: (use a separate

sheet if necessary) ………………………………………………....…………………………………………………………………………………………..…………………………………………………………………………………………..…………………………………………………………………………………………..………………………………………………………………………

Legal marital status:

Married Divorced Single

Any outside agency involved, for example:

Special Education Needs (SEN), Health Visitor, Social Care Services, Hospital Consultant, Dietician, Speech & Language Therapy (SALT), IDVA/ MARAC, Early Help Assessment team (EHA)

If yes, please describe: ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Who has parental responsibility? Mum Dad Both

Any other cases related to your child:

Child Protection Looked After

Name of key person/ lead professional in case work and contact details:

……………………………………………………………………………………………………………………………………………………………………………………………………………………………………

MEDICAL INFORMATIONHas your child had the following checkups done, PLEASE TICK BELOW CHECKUPS THAT HAVE BEEN DONE?

2 MONTH DTaP-IPV-Hib, PCV, Rotavirus

3 MOTNH DTaP-IPV-Hib, PCV, Rotavirus

4 MONTH DTaP-IPV-Hib, PCV, Rotavirus

12 MONTH MMR, Varicella, Hepatitis A

18 MONTH Hepatitis A

2-3 YEARS Catch-up vaccines

4-5 YEARS DTaP-IPV, MMR-Varicella

MEDICAL INFORMATIONFull Name of Child’s Doctor: ……………………………………….....................

Full Name / Address of Surgery: ……………………………………………………………………………………………………………………………………………..Postcode: ………………………………………. Telephone:………………….....

Does your child suffer from any illness, disability or allergy? Yes NoIf Yes, please give further details: ………………………………………………….……………………………………………………………………………………….....

Does your child have any special dietary requirements? Yes NoIf Yes, please give details, particularly of the foods to avoid: …………………...……………………………………………………………………………………….....

Does your child wear glasses? Yes NoDoes your child wear a hearing aid? Yes No Will your child be bringing any medication to school? Yes NoIf Yes, please give details: …………………………………………………………..…………………………………………………………………………………….........

Any other important medical information? …................................................…………………………………………………………………………………………..…………………………………………………………………………………………..

I / We hereby give permission for any member of school staff who is a Paediatric First Aider to administer emergency medicine, advise or treatment, and to take my child to hospital should the need arise.

I / We will not hold the school responsible for the implementation of the above.

Full Name of Parent / Guardian: ..................................................................... Signature: ………………………... Today’s Date: …………………..........

DENTIST INFORMATIONFull Name of Child’s Dentist surgeon: ……………………………………….....................

Full Name / Address of Surgery: ……………………………………………………………………………………………………….Postcode:……………………Telephone:………………….....

When was your child last visit at the dentist? ……………………………………………………………………………………….....

Has your child had any dental treatment/ surgery? Yes NoIf Yes, please give details, particularly of the foods to avoid: …………………...……………………………………………………………………………………….....

Any other important information? ….........................................................................................................................................................

OTHER SETTINGS YOUR CHILD HAS ATTENDED (1) Name of Setting: .........................................................................

Date From: ................................ Date To: ................................

(2) Name of Setting: .........................................................................Date From: ................................ Date To: ................................

Please bring your child’s Early Years Foundation Stage Progress Tracker and any record of achievements from your child’s last setting.

PARENT DECLARATION FOR TOILET TRAININGWe will endeavour to have our children fully toilet trained by the time they are admitted to the Nursery at Oakwood Primary School. We will supply fully labelled change of clothes so in the

event of clothes being soiled they can be changed.

Signature: ……………………………………………. Date: …………………

DECLARATIONI apply for admission of my child to this pre-school and certify that all the above details are correct to the best of my knowledge. I undertake to honour in full the requirements of my child’s agreed study programme, and

all Oakwood Early Years Rules, Regulations & Policies.

I have returned this completed form with a copy of my child’s birth certificate to reserve a place for my child.

I agree that if my child's agreed hours are more than 15 hours a week, to pay any nursery fees at the beginning of each month in full at the rate of £5.00 for every hour over 15 hours a week. I acknowledge and

agree that all monies paid to Oakwood Education are non-refundable.

Full Name of Parent / Guardian: ..................................................................... Signature: ………………………... Today’s Date: ………………….........

Please return completed application form to:OAKWOOD PRIMARY SCHOOL, 117 TENNYSON ROAD, LUTON, BEDFORDSHIRE, LU1 3RR

Thank you for your co-operation. Please remember to keep us informed of any changes in your circumstances so that records can be updated. All personal information is kept strictly confidential and will only be passed on in an emergency or official situation

All About MePlease answer these questions in as much detail as possible.

This will help us to get to know your child and help him or her to settle in quickly.

My name is: ………………………………………………………………………………….......................

I was born on (DOB): ……………………………………………………………………………………………………..

My favourite food is: ………………………………………………………………………...................

I don’t like eating and drinking: …………………………………………………………………...........

I am intolerant/ allergic to: ………………………………………………...............……………….

I need medication for: ………………………………………………………………………………………….......

I like to have a nap at: …………………………………………………………….......................

I can use the toilet: ……………………………………………………………………………….............……

I wear nappies/ pull ups: …………………………………………………………………………….............

My favourite toy is: …………………………………………………………………………………………..........

My favourite story is: …………………………………………………………………………………….….........

When I’m feeling sad or need a nap I like to: (e.g. have my comforter): …………………………………………………………………………………………………………...…….…………………………………

I live with my: ………………………………………………………………………………………………................

At home my first language is: ………………………………………………...……………………..…………...

In my family I have a sister: ……………………………………………………………..…………………......

In my family I have a brother: …………………………………………………………………..…...………..

I have regularly contact with other adults who do not live in my house for example: aunty, uncle, cousin. Their names are: …………………………………………………………………………………………………………………………………………….

I have a pet and my pet’s name is: …………………………………………………………………………….…

My favourite nursery rhyme/ nasheed is: …………………………………………………..………….…

I have learned these surahs: …………………………………………………………………………………………

This is what I can do well: …………………………………………………………….…………………………………………………………………………………….

These are my likes and dislikes: ………………………………………………………………………………………

This is what I am working on at home with my parents/ carers: ………………………………………………………………………………………………………………………………………………………

I enjoy these physical activities: ……………………………………………………………...............

I have difficulty with these activities: …………………………………………………………………………

Things I might need help with: ………………………………………………………………………………………………….……………………………………………………

Date: …………………………………..

Parents/ carer signature: ……………………………………………………….

Please bring in a drawing/ picture/ sample of work that your child has produced at home. This will help us to understand better the stage of development your child has reached.

Parent Permission SlipChild’s Name: -------------------------------------------------------------

I / We give permission for the following:

For Paediatric First Aider to administer medicines YES/ NOE.g. – creams given by parents for skin problems, inhalers given by parents for asthma, junior paracetamol for fever, antibiotics given by parents for infection to help complete daily regime

For staff to seek emergency medical advice and treatment YES/ NO

For staff to take photographs of my child and use them for assessment YES/ NOand display purposes within nursery setting.

For staff to carry out observations on my child for assessment YES/ NOand progress trackers

For staff to share information about my child with adults other than parents YES/ NOe.g. another adult with consent to collect your child and staff need to share a concern

For my child to use the soft play areas and large garden play equipment at school YES/ NOIncluding – climbing frames, ropes and step apparatus

For my child to go on short outings to local public parks and use park play equipment YES/ NO

For my child to go on accompanied short walks around footpaths near school building YES/ NO

For my child to go on local school trips for educational purposes YES/ NOe.g. local library, Discovery Centre, Baylands Horse-Riding Centre

For the Early Years Manager to send my child’s EYFS Progress Tracker YES/ NOto the next setting/ school my child will attend

For staff to apply sticking plasters for small cuts YES/ NO

For staff to change my child’s clothes in case of a toileting accident YES/ NO

For staff to apply sun protection lotion in summer YES/ NO

Parent/ Carer Name:--------------------------------------------------

Parent/ Carer Signature: --------------------------------------------

Date: --------------------------------------------------------------------------

Consent to Share Information

To be signed by the person with Parental Responsibility

This form contains your consent to the sharing of information between the organisations identified below. The consent applies to the children named below and where necessary may include information about the child’s health, welfare and development and the child’s home or family circumstances.

If you give permission, information will be shared with relevant organisations amongst those listed, to assist the effective provision of family support, education or health services to the child/children named below. This consent can be withdrawn at any time and will be reviewed annually to ensure continued validity. It applies to information already held on the file or record and to information subsequently added.

Organisations include:

Luton Borough Council (including Rapid Intervention & Assessment Team, Early Years Education Consultants, Integrated Services for Children with Additional Needs Team, Early Help Assessment Team, Local Authority Designated Officer, Early Years MARAC)

Schools and Ofsted registered Early Years providers

Your Local Children’s centre (insert name): ABC Children’s Centre

Health Service (including Health Visitor, GP, Consultant, Speech and Language support services

Other …………………………………………………………………………………

Are there any of these organisations you do NOT want us to share information with? (List these here)

Child’s Full Name: ………………………………………………………………. Date of Birth …………………………

I agree to the personal information of the individuals named below being shared for the purpose of providing services to promote their welfare and meet their identified needs.

Name: (Print) ____________________________ Signed:______________________________

Date of signature:_________________(parent/guardian)

I do not agree to the personal information of the individuals named below being shared for the purpose of providing services to promote their welfare and meet their identified needs.

Early Years Manager: Ms Zameed Akhtar117 Tennyson Road, Luton, and Bedfordshire, LU1 3RR Tel: (01582) 518800 E-mail:

admin@oakwoodprimary.co.uk

Name: (Print) ____________________________ Signed:_______________________________ Date of signature:_________________(parent/guardian)

I am satisfied that the person is capable of understanding the information that I have given to them

Name: (Print) ____________________________ Signed: ______________________________

Date of signature: ________________

Organisation/Service:_________________________________________________________________

Adapted from Luton LSCB: Consent to Share ProForma online http://bedfordscb.proceduresonline.com/pdfs/LSCB%20Consent%20To%20Share%20ProForma%20V1%201.pdf

Office Use only:

Annual review completed (date): ______________________

Changes required: Yes No

if yes complete a new Information Sharing Consent form

Reviewed by (print name) ______________________________________________________________

Photograph PermissionAssalamu ‘alaikum wa rahmatulahi wa barakatuh,

To provide supporting evidence for the Early Years Progress Tracker, we take regular photographs of the children at our Nursery. These are used within the setting for display purposes and put into the children’s trackers and folders.

Photographs are also taken during all school events and trips such as Sports Day, Play productions, Award ceremonies, External Visits, World Book Day, Horse-riding and so on. We may need to use these images in our School’s Prospectus, Welcome Packs, Advertisement flyers or in other printed materials that we need to produce, as well as on our Website and Facebook page. We may also make videos for other educational or promotional uses.

We seek your permission to use your child’s photograph for the following:

School prospectus and other printed publications that we produce for promotional purposes School Website School Facebook page Video recording Media purposes

Please answer the question below, then sign and date the form where shown and return the completed form to the school. If we do not receive the slip we will assume your consent and use your child’s photographs as mentioned above. If you require any further assistance, please do not hesitate to contact the Nursery Manager.

Wa salamu ‘alaikum wa rahmatulahi wa barakatuh,

______________________Faisal khanHeadTeacher............................................................................................................................................................................Name of Child: _____________________________________________________________________Class: NURSERY

Having read the above statements, do you give

consent for photographs of your child to be used as

mentioned above?(Please tick the appropriate box)

YES, I give my consent for photographs of my child to be used as mentioned above.

NO, I do not give my permission for photographs of my child to be used as mentioned above.

I have read and understood the conditions of use of school photographs of my child on this form.

Parent(s)/carer(s) Signature: ___________________________________________ Date: __________________

Name (capitals): _____________________________________________________

Agreement and Acceptable Use Policy for Internet Use in Oakwood Early Years

(Nursery and Reception classes)

Dear Parents/ Carers,

As part of your child’s learning and development opportunities there are times when it would be beneficial for children to have access to the internet. While on the internet children will be supervised by an adult at all times. Any websites the children access will be evaluated by staff for their suitability for young children before they are used in Oakwood Early Years.

The setting will have an Internet Service Provider [ISP] that uses the latest screening techniques to prevent access to all categories of unsuitable, offensive and inflammatory Internet materials.

In Oakwood Early Years we believe that both staff and children benefit from access to internet resources. Nevertheless, we respect the right of Parents/Guardians to decide whether or not to agree internet access for their children.

Please read the guidelines below and then complete and return the attached form overleaf.

The E-Safety policy summary can be found in the Nursery Welcome Pack that will be given to you before your child begins.

Guidelines – Internet Acceptable Use PolicyChildren within Oakwood Early Years

1. Only children whose parents have signed an agreement form to give permission for internet access will be allowed to use the internet.

2. Children will be supervised by an adult at all times when accessing the internet.

3. Any websites used with children will have been previously evaluated by an adult suitability for use with young children.

4. An Internet Services Provider that uses the latest screening techniques to prevent access to all categories of unsuitable, offensive and inflammatory Internet materials.

Please complete and return this form to the Manager/Leader of Oakwood Early Years

Children within Nursery or Reception

Complete this section only if you do wish your child to have supervised access to the internet.

I have read the Conditions of the Internet Acceptable Use Policy of Oakwood Early Years. I would like my child to have supervised access to the internet.

Name of child:

Name of parent/ carer:

Signature of parent/ carer:

Date:

Complete this section only if you do not wish your child to have supervised access to the internet.

I have read the Conditions of the Internet Acceptable Use Policy of Oakwood Early Years. I would not like my child to have supervised access to the internet.

Name of child:

Name of parent/ carer:

Signature of parent/ carer:

Date:

Password System for Children in

Oakwood Early Years

Oakwood Early has a password system in place to make the collection of children from our setting more secure.

Parents will need to provide a ‘password’ to us that all parents, relatives or family friends will need to say to the staff before a child is released to that person.

It is better if the password is a short, single word with no numbers that is easy to memorise e.g. sunset.

This password needs to be kept amongst the persons with permission from the parents to collect their child, and not made known to other parties.

Oakwood Primary School will maintain confidentiality of the password.

Your child will only be released to the persons mentioned on the password form who say the correct password to staff. They will not be released to anyone not on the form or if the person collecting the child does not say the password.

Once the staff are familiar with the persons on the password form, they will no longer ask for the password.

Password Form

Name of Child: ...................................................................................................Class: NURSERY

Persons with permission to collect the above mentioned child: (include parent names)

NAME Relationship to Child1)................................................................................ ...................................................

2)................................................................................ ...................................................

3)................................................................................ ...................................................

4)................................................................................ ...................................................

5)................................................................................ ...................................................

Password: .................................................................(One short, single word)

I understand that this password will need to be said to Oakwood Primary School staff before my child is released to any of the persons above.

I understand that the password must be kept amongst the persons mentioned above and not disclosed to anyone else.

Parent/ Carer Name: ...............................................................................

Signature: .......................................................................................

Date: ...............................................................................................

Attendance Form for NurseryAll nursery children are eligible for 15 hours of free nursery education per week beginning on the term after the 3rd birthday.

Our Nursery offers flexible attendance hours to help accommodate parents’ busy schedules.

Please choose a structure that best suits you below.

Nursery Session Times

Flexible Hours Structure

Days Timings Hours attending per week

1 5 mornings 9.30am-12.30pm (3 hrs inc lunchtime) 15 hrs2 5 afternoons 12.30-3.30pm (3 hrs, no lunchtime) 15 hrs3A3B

Full days 9.30am-3.30pm (6 hrs inc. lunchtime)8.30am-3.30pm (7 hrs inc. lunchtime)

Clarify your chosen hours:

Structure chosene.g. 1

Hours attendinge.g. 9.30am – 12.30am

MondayTuesdayWednesdayThursdayFriday

TOTAL HOURS A WEEK =

I understand that these timings can be permanently changed only once during each term. One off daily changes can be made for appointments or emergencies at the Early Years Manager’s discretion, please give at least 1 days notice.

I understand that my child is eligible for 15 hours of free nursery education per week.

I understand that there is a fee for attending more than 15 hours a week and that this fee is £5.00 per extra hour.

I understand that the fee for extra hours is to be paid online via Parent Pay on a half termly basis by the date indicated on the invoice and that the fee is non-refundable.

I understand that unpaid invoices may result in my child not being able to attend the following term at Oakwood Nursery.

Children must arrive and depart from Nursery on time. We cannot accommodate very early arrivals and late departures will incur a £5 fine for every instance.

Parent/ Carer name: …………………………………………………………….

Parent/ Carer signature: …………………………………………………….….

Date: ……………………………………………

30 Hours Entitlement in NurseryThe 30 hours entitlement for free childcare for 3 and 4 year olds in Nursery has been available from September 2017 for working parents.

All children who are 3 and 4 years old will receive 15 hours of free childcare a week. Please read on to see how you can check if you qualify for the additional 15 hours of free childcare taking you up to 30 hours a week and how to apply for it.

If you’re a parent of a three or four year old, you will need to meet the following criteria in order to be eligible for 30 hours free childcare.

Both parents must be in work, or for single parent families, the sole parent must be at work. ‘In work” is defined as being in employment (including self-employed) and earning at least the equivalent of 16 hours per week at National Minimum Wage or National Living Wage.Each parent must earn less than £100,000 per year.

Families will also be eligible if both parents are employed but one parent (or both parents) are:

temporarily away from the workplace on maternity, paternity, adoption or parental leave temporarily away from the workplace on statutory sick pay

Or if:

one parent is employed and one parent has substantial caring responsibilities based on specific be-nefits received for caring

one parent is employed and one parent is disabled or incapacitated and in receipt of specific bene-fits.

As a parent you will be responsible for checking your eligibility online at www.childcarechoices.gov.uk

You can apply online at www.childcare-support.tax.service.gov.uk or by calling 0300 123 4097 (or 0300 129 9232 for Minicom).

If you are eligible for the additional 15 hours, you will receive an eligibility code. You need to bring that, along with your national insurance number and child’s date of birth, to the Early Years Manager at Oakwood Nursery before admission. This will enable you to claim the 30 hours of free childcare. All free childcare either 15 or 30 hours will commence the term after your child becomes 3 years old. You can choose for your child to attend more than one childcare provider; however you cannot use more than two sites in one day. You will also be required to reconfirm your eligibility with HMRC every three months.

Please be aware that all extra hours over 15 hours a week or 30 hours a week (if you qualify for the additional 15 hours a week) will be charged at £5 per extra hour. Invoices are sent out every half term and need to be paid by the date indicated in the invoice. Unpaid invoices may result in your child not being able to attend the following term at Oakwood Nursery.

I have read and understood the above statement regarding invoices for extra hours attended in Nursery.

Parent signature: ……………………………………………………………….

I have claimed the 30 hours a week of free Nursery childcare:

ELIGIBILITY CODENATIONAL INSURANCE NUMBERFULL NAME OF PARENT

SCHOOL TEXT MESSAGING SERVICE

We have a text messaging service in place in order to have a better and faster communication system in place. This will allow our school to communicate with all parents whilst saving time & money as well as dramatically improving the way we communicate with you. By using Text messages we send information, short texts, alerts and reminders to parents within seconds.

We are calling this communication ‘homeContact’

HomeContact has been designed with you in mind, because we know how time consuming it can be to produce letters for parents, and how quickly circumstances and arrangements can change. It can also provide a great way for parents to be kept fully informed - easily!

Please note: Parents must complete the slip below and give details of the main contact number where the school will send the text message.

If you require any further assistance, please do not hesitate to contact the School Office. ............................................................................................................................................

Home Contact and School Texting Service.

Please return the completed slip to the school office.

Name of Parent/ Carer ___________________________________________________

Name of child ____________________________________________________

Year Group _________________________

Main contact Mobile number _________________________________________________________(where you prefer to receive a text message from the school)

Email- address: ……………………………………………………………………………..

Safeguarding Statement“At our school, the health, safety and well-being of every child is our paramount concern. We listen to our pupils and take seriously what they tell us. Our aim is that children will enjoy their time as pupils in this

school. We want to work in partnership with you to help your child to achieve their full potential and make a positive contribution.

To promote a safe environment for pupils, our selection and recruitment policy includes all checks on staff and regular volunteers’ suitability, including Vetting and Barring Checks, as recommended by Luton Bor-ough Council in accordance with current legislation.

In accordance with our responsibilities under section 175 {Section 157 for Independent Schools and Academies} of the Education Act 2002, we have a Designated Person for Child Protection who is a mem-ber of the senior management team, and has received appropriate training for this role.  It is her responsib-ility to ensure that all staff in contact with children receives child protection awareness training on a regular basis.

On rare occasions our concern about a child may mean that we have to consult other agencies.  Un-less it is not safe for a child, we would always aim to achieve this with a parent's consent.  The pro-cedures, which we follow, have been laid down by the Luton Safeguarding Children Board (LSCB),

and the school has adopted a Child Protection Policy in line with this for the safety of all.

If you want to know more about our procedures, please speak to the Designated Safeguarding Officers for Oakwood Primary School:

Mr Faisal Khan (LSCB Safeguarding Level 3) – Early Years Manager – Lead SGO

Our Safeguarding procedures involve keeping confidential records of any concerns a staff member may have about a child, which may range from an unexplained mark, scratch, bruise or cut to something more serious.

I have read and understood the following statement.

Parent/ Carer Name:------------------------------------------------------

Parent/ Carer Signature: ------------------------------------------------

Date: --------------------------------------------------------------------------