Child's Details

Full Name (required)

Date of Birth (required)
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Gender:
—Please choose an option—malefemaleprefer not to answer

Religion

Parent #1 Details

Full Name (required)

Relationship to child
—Please choose an option—MotherFatherOther

Address (required)

Postcode

Telephone Home (required - use mobile if no home number)

Telephone Mobile (required - use home if no mobile number)

Telephone Work

Email Address (required)

Parent #2 Details

Full Name (required)

Relationship to child
—Please choose an option—MotherFatherOther

Address (required)

Postcode

Telephone Home (required - use mobile if no home number)

Telephone Mobile (required - use home if no mobile number)

Telephone Work

Email Address (required)

Enrolment Details

Start Date (required)
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Sessions required

Mon
Tue
Wed
Thu
Fri

Please note: You will need to allow a week before this date for the settling-in process.

Have you already been to visit the nursery?
—Please choose an option—yesno
(If not, please call 01992 937 999 and we can get this booked in for you)

Has your child attended any previous childcare settings? (this includes a nursery or child minder)
—Please choose an option—yesno
If yes, please list all settings

Does your child have any additional needs?

Additional Information

Where did you hear about Chrysalis?

please check that you have filled in all the required fields before pressing send.

Data Protection
Should you not join Chrysalis Nursery and Pre-school for any reason, we will retain this form until you request to be removed from the waiting list or until your child reaches 5 years of age.