St Nicholas Catholic Primary School

Breakfast & After School Club

Registration Form

Child’s Full Name: _______________________________________ Gender: M / F (Please Circle)

Preferred Name: _______________________________________ Date of Birth: ____/_____/_____

Languages Spoken: ______________________________________ Religion: ___________________________

Ethnic background: ______________________________________ Password*: __________________________

*Please ensure you provide a password that will be used if someone unknown to us picks up your child. The 

password should not include your child’s name in any form.

Parent/Guardian (1): Parent/Guardian (2):

Full Name: Full name:

Address: Address: (if different)

Do you have parental responsibility? .............. Do you have parental responsibility?

Tick if this is child’s main address Tick if this is child’s main address

Home Tel: Home Tel:

Work Tel: Work Tel:

Mobile: Mobile:

Email Email:

Full Name: Relationship to child:

Tel: Mobile:

Other people authorised to collect the child:

Name: ...................................................... Relationship to child: ...............................................

Name: ...................................................... Relationship to child: ...............................................

Child’s GP: ______________________________________ Telephone Number: __________________________

Does your child have any Medical conditions? E.g. allergies, asthma, food? Yes / No 

Does your child have a statement of special educational needs? Yes / No

Any other relevant information that we may need to know about? Yes / No

If you have answered yes to any of the above questions, please ensure to complete the additional ‘All About Me’ form, which 

relates to how the staff at the Breakfast and After School Club can best support and meet your child’s needs. 

What is his/her behaviour generally like? ................................................................................................

Does he/she have any behaviour problems? Yes / No

If ‘yes’ what are they? (I.e. temper tantrums, tearfulness, nervous habits, hair pulling etc).................................

.......................................................................................................................................................

Is your child verbally aggressive? Yes / No

Is your child physically aggressive? Yes / No

Is your child shy or withdrawn? Yes / No

Does he/she get on well with other children? Yes / No

Does he/she get on well with other adults? Yes / No

Do they have any fears? Yes / No If yes what are they?

.......................................................................................................................................................

Is there anything else that you think we should know?...........................................................................

.......................................................................................................................................................

What does he/she especially like doing? ................................................................................................

What doesn’t he/she like doing? ............................................................................................................

Please list any foods your child will not or would prefer not to eat (please put dietary needs/allergies on the All About Me form) -

_________________________________________________________________________

Please note that a full set of policies and procedures relating to the Breakfast and After School Club is available in the school office for you to read. Please request this at any time.

All Parents / Carers must complete this section.
Children cannot be accepted unless this form is signed and dated.

I hereby consent for my child to take up a place at St Nicholas Breakfast and/or After School Club, according to the terms and conditions set out in its policies and procedures. I understand that persistent late or non-payment of fees will jeopardise my child’s continued attendance at the club. I confirm that the information given on this form is correct, that I am the legal parent / guardian of this child and I will contact the Playleader in the event that any of the details change.

Signature Parent/Carer: .......................................................... Dated: ..................................

Please also complete the following consents:

Do you consent for your child to take part in face painting activities? Yes / No

Do you consent for your child to watch PG rated movies? Yes / No

Do you consent for your child to be taken on trips, off the school premises? Yes / No

Do you consent for your child to be photographed for display purposes within the Yes / No

School building and publicity for the club?

Do you consent for your child to take part in various water activities? Yes / No

(i.e., water slide, paddling pool, water fights etc)

Please return this form to the Playleader or the school office.

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BASC CONTACT INFORMATION

Club Mobile: 07833545070

Club e-mail: ilamb@stncs.uk

Website: www.st-nicholas-exeter.devon.sch.uk

Address: BASC, St. Nicholas Catholic Primary School, Ringswell Avenue, Exeter, Devon, EX1 3EG