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* 1. Full Name of Child

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* 2. Date of Birth

Date

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* 3. Gender

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* 4. Current Address

Details of those with legal parental responsibility

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* 5. PARENT OR GUARDIAN  1

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* 6. PARENT OR GUARDIAN 2

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* 7. I would prefer:

I understand that I need to apply for 30 hour funding, and must provide Temple Hill Primary Academy with a 30 hour code the term my child named above turns 3. Failure to do so will result in only a 15 hour funded place being secured.

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* 8. Details of siblings currently attending Temple Hill Primary Academy

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* 9. Has your child any special education, social, emotional or medical reasons for admission to this nursery?

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* 10. If ‘yes’, please give details

The information on this form is correct to the best of my knowledge and belief.

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* 11. Name

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* 12. Date

Date
If your child is offered a place, you will need to provide proof of address and the original birth certificate or passport of your child.
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