APPLICATION FOR ADMISSION

CHILD'S PARTICULARS

MOTHER'S/GUARDIAN'S PARTICULARS

FATHER'S/GUARDIAN'S PARTICULARS

MEDICAL INFORMATION

Please enclose photocopies of your child vaccination/immunisation certificate, indicating the dates i.e. poliomyelitis, trip antigen, measles and types of vaccinations.

Past History of Infectious Disease

Allergy

Physical Disabilities

FAMILY DOCTOR

SOCIAL INFORMATION

EMERGENCY

In case of emergency when both parents cannot be contacted, please call any persons named below.

CONSENT

Medical Authorisation

In the event that I cannot be reached at the time of illness or accident, permission is hereby granted to Bethel Child Development Centre and its staff to call a licensed physician of their selection or if hospitalisation is needed, my child will be sent to the nearest hospital and the medical fees and any other expenses such as transportation incurred on behalf of my child will be borned by me.

General Permission

ln the event of any supervised field trips, excursions, outings or while my child is at the centre, I will not hold the Centre or its Staff responsible for any unfortunate accident, injuries, loss of personal items or lives.

The following named individual is the only person authorised to pick up my child at the Centre. I will not hold the Centre for any damages, claims or liabilities which might result from the Centre and its staff releasing my child to any persons named below:

I declare that the information provided in this application by me is true and I furnish it knowing that I may be liable to prosecution if I have wilfully stated any information which I know to be false or do not believe to be true. I also understand that any part of this application improperly completed may lead to the rejection of the application.

I hereby consent to the Ministry of Community Development and Sports releasing my particulars and those of my child/children presently in the childcare centre to the Health Promotion Board (HPB). I also consent to my child/children being screened under the health programmes of HPB. I understand that HPB will keep my particulars and those of my child/children strictly confidential.

FOR OFFICIAL USE ONLY
VERIFICATION OF ELIGIBILITY

I have verified the foregoing information to be true and understand that our centre may be liable to prosecution for any information furnished by the applicant which I know to be false or do not believe to be true. I understand that any part of this application improperly completed may lead to the rejection of the application.