Please enable JavaScript in your browser to complete this form.Child's Name *FirstLastGender *BoyGirlChild's Date of Birth *Child's Ethnic Origin *Child's Country of Birth *Child's Nationality *Religion *Home Address *Child's Home Language *Other Languages Spoken *Parent / Carer 1 Name *Parent / Carer 1 Title *MrMrsMsMissParent / Carer 1 Email Address *Lone Parent *NoYesParent / Carer 1 Phone Number *Parent / Carer 1 Occupation *Parent / Carer 1 National Insurance Number *Parent / Carer 1 Ethnic Origin *Parent / Carer 1 Nationality *Parent / Carer 2 NameParent / Carer 2 TitleMrMrsMsMissParent / Carer 2 Phone NumberParent / Carer 2 OccupationParent / Carer 2 National Insurance NumberDoes your child have additional needs or health issues? *Does your child receive support from the Child Development Centre, Speech and Language Therapy or other service? *Is your child “looked after” or supported by an Early Help Plan or Social Services? *Is your child accessing Disability Living Allowance (DLA)? *YesNoDoes your child have (or in the process of gaining) an Education, Health and Care Plan (EHCP)? *YesNoHas your child attended any other childcare settings? E.g. childminder, relatives or another nursery setting. *Preferred Start Date *Fee Paying Orchard Room Places – for 3 months to 3 years old - Please indicate your preferred childcare requirements by ticking the appropriate boxes below. Children must attend a minimum of three morning or afternoon session. The Orchard Room will be closed each year for 10 closure days, 5 inset days and all statutory public holidays; you will not be charged for these days.8.00am – 1.00pm £32.00 includes breakfast and lunchMondayTuesdayWednesdayThursdayFriday8.00am – 4.30pm £53.00 includes breakfast lunch and teaMondayTuesdayWednesdayThursdayFriday8.00am – 6.00pm £63.00 includes breakfast lunch and tea MondayTuesdayWednesdayThursdayFriday1.00pm – 4.30pm £22.00 includes teaMondayTuesdayWednesdayThursdayFriday1.00pm – 6.00pm £32 includes teaMondayTuesdayWednesdayThursdayFriday2 Year Funded Children Some 2 year olds will be entitled to free funded childcare of 15 hours per week during term time, starting the term after their second birthday. You will need to provide your valid funding code before we can process your application. For more information and to check your eligibility please go to: www.childcarechoices.gov.uk Have you applied for or been accepted for 2 Year Funding?YesNo2 Year Funding Reference NumberIf eligible please choose one of the following attendance patterns (term time only):Mornings, Monday - Friday 8.45am – 11.45amAfternoons, Monday - Friday 12.45pm – 15.45pmI have parental rights for the child named in this application. *NameSubmit