UPG & FAMILY SUPPORT CHILDREN’S CENTRE ENROLMENT FORM

PARENT 1 – All sections need to be filled in to fully complete registration

First Name *

Middle name *

Family name *

Relationship to child *

Gender

Male

Female

Date of Birth

What is your Ethnic Group

What is your Religion?

Do you have any disabilities?

Are you a Lone Parent?

Yes

No

Are you currently Employed?

Employed

Unemployed

Home phone number *

Work phone number *

Email address

If parent/carer is pregnant, what is the estimated delivery date?

PARENT 2 – All sections need to be filled in to fully complete registration

First Name *

Middle name *

Family name *

Relationship to child *

Gender

Male

Female

Date of Birth

What is your Ethnic Group

What is your Religion?

Do you have any disabilities?

Are you a Lone Parent?

Yes

No

Are you currently Employed?

Employed

Unemployed

Home phone number *

Work phone number *

Email address

If parent/carer is pregnant, what is the estimated delivery date?

CHILD 1 – All sections need to be filled in to fully complete registration

First Name *

Middle name *

Family Name *

Date of birth

Gender

Male

Female

Child's Ethnic Group

Child's Religion?

Does the child have any disabilities?

CHILD 2 – All sections need to be filled in to fully complete registration

First Name *

Middle name *

Family Name *

Date of birth

Gender

Male

Female

Child's Ethnic Group

Child's Religion

Does the child have any disabilities?

CHILD 3 – All sections need to be filled in to fully complete registration

First Name *

Middle name *

Family Name *

Date of birth

Gender

Male

Female

Child's Ethnic Group

Child's Religion

Does the child have any disabilities?

NANNY/CHILDMINDER – All sections need to be filled in to fully complete registration

First Name *

Middle name *

Family Name *

Gender

Male

Female

Ethnic Group

ABOUT YOUR FAMILY

The following section asks questions to help us understand your needs and those of your family so that we can offer you appropriate support and make sure you have access to the services you need.

Questions about your family’s housing support needs

Do you need support with any housing difficulties?

YES

NO

Are you living in temporary housing?

YES

NO

Questions about your family’s financial support needs

Are you living in a household where no one is working?

YES

NO

Is anyone in the household claiming benefits? Please state (not child tax credit)

YES

NO

Do you have ‘No Status’? If so, please let us know why:

YES

NO

Are you or your family seeking asylum in the UK?

Yes

No

Questions about your child/ren and the support they need

Do you or your children have a specialist early intervention health visitor?

Yes

No

Children_support_needed_Q1

Yes

No

Are any of the children on this form currently in foster care?

Yes

No

Questions about you and the support you need

Have you received or would you like support for your mental health?

Yes

No

Have you ever been affected by domestic abuse?

Yes

No

Do you need support in speaking English? (i.e. an interpretor)

Yes

No

Do you need support with reading and writing in English?

Yes

No

Would you like more information about our family support services?

Yes

No

Would you like information on our parenting programmes?

Yes

No

Would you like information on our adult education classes?

Yes

No

Do you receive Healthy Start Vouchers?

Yes

No

Would you like help in registering for a nursery place?

Yes

No

Other – Please sign and date below to fully complete registration

Are there any other areas you would like support in?

How did you find out about us?

I consent to being contacted

Date

DATA PROTECTION

UPG and Family Support are committed to protecting your personal data and being clear and honest about how your data is used. Your data will only be used for the purposes of monitoring attendance, your child’s development (additional consent will be requested) and anonymous, confidential reporting to our governing and statutory bodies. By enrolling at any Hammersmith and Fulham Children’s Centre you are consenting for your personal data to be stored on the Estart (Children’s Centre data base) which can only be accessed by Family Support authorised users in the London Borough of Hammersmith and Fulham.

Your data will be retained electronically until your youngest child turns 5. We will not share your data with a 3rd party without further consent from you, with the exception of safeguarding where we have a statutory obligation to report any safety concerns around a child. You have the right to request to see how your personal data is stored and may at any time view our privacy policy and have the right to withdraw your consent at any time.

Please tick consent box, sign and date below to fully complete registration

By signing I consent for my family’s personal data to be stored and used as outlined above.

I consent for photographs to be taken of my child during Children’s Centre sessions and be used within Children’s Centres for displays and recording, which may be viewed by other Children’s Centre users.

Name:

Signed:

UPG & FAMILY SUPPORT CHILDREN’S CENTRE ENROLMENT FORM

PARENT 1 – All sections need to be filled in to fully complete registration

PARENT 2 – All sections need to be filled in to fully complete registration

CHILD 1 – All sections need to be filled in to fully complete registration

CHILD 2 – All sections need to be filled in to fully complete registration

CHILD 3 – All sections need to be filled in to fully complete registration

NANNY/CHILDMINDER – All sections need to be filled in to fully complete registration

ABOUT YOUR FAMILY

The following section asks questions to help us understand your needs and those of your family so that we can offer you appropriate support and make sure you have access to the services you need.

Questions about your family’s housing support needs

Questions about your family’s financial support needs

Questions about your child/ren and the support they need

Questions about you and the support you need

Other – Please sign and date below to fully complete registration

DATA PROTECTION

Please tick consent box, sign and date below to fully complete registration

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