Record No: Centre: Cocoon Childcare

1st Floor, Moritz House

Ballycullen,
Tallaght,

BOOKING FORM 2021 Dublin 24

Ph: 01 4199999
Fax: 01 419 99 98
All Areas Must Be Completed & Signed In Full -Please use Block Capitals Email:
info@cocoonchildcare.ie

Scheme Afterschool
Name of Scheme Care Option Parent CHICK code School Name
(ECCE/NCS) Monthly Bus collection Yes No
Contribution
School drop off time
School pick up time
Option 1 12 Month Fee Structure
Has proof of relevant scheme eligibility been provided? Sep to Aug Inclusive
Option 2 10 Month Fee Structure
Sep to June Inclusive
Child’s Personal Details
Child’s Surname Name: Date of Birth:

Child’s First Name: Home Tel. No:

Child’s Middle Names: Gender:

Child Affectionately known as: “ “

Correspondence Address: Correspondence Email:

Date of Commencement: Finishing Date:

(Date from which fees will be incurred)
/ / / /
Parent / Guardian Personal Details
Number of Legal Guardians:

Parent/ Guardian 1 Name: Parent/ Guardian 2 Name:

Parent/ Guardian Date of Birth: Parent/ Guardian Date of Birth:

Parent/ Guardian Occupation: Parent/ Guardian Occupation:

Company Name: Company Name:

Work Address: Work Address:

Parent/ Guardian Mobile No: Parent/ Guardian Mobile No:

Parent/ Guardian Work Contact No: Parent/ Guardian Work Contact No:

Parent/ Guardian Home Contact No: Parent/ Guardian Home Contact No:

Parent/ Guardian Home Address: Parent/ Guardian Home Address:

Parent/ Guardian 1 Email: Parent/ Guardian 2 Email:

Who does child live with: Parent/ Guardian 1  Parent/ Guardian 2 Collection Password:
Please Tick

Designated people to collect child (other than parents)

(1) Name: (2) Name:

Relationship to child: Relationship to child:

Tel No: Tel No:

(3) Name: (4) Name:

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 Relationship to child: Relationship to child:

Tel No: Tel No:

Nominated emergency contact persons (other than parents)

(1) Name: (2) Name:

Relationship to child: Relationship to child:

Tel No 1: Tel No 1:

Medical Details
Family Doctor: Tel No:

Address:

Immunisation Record Please tick and enter date

B.C.G PCV Meningitis C MMR
6 in 1
Diphtheria Tetanus Hepatitis B □ □ □
Polio HIB Whooping Date: Date: Date:
Cough
□ □ □ □ ___/___/___ ___/___/___

Date: Date: Date: Date: ___/___/____ ___/___/____ ___/___/___

___/___/____ ___/___/____ ___/___/____ ___/___/____ ___/___/___ ___/___/___ ___/___/____

Does your child suffer from any medical conditions? □ YES □ NO

If YES, please state condition and provide written details of any requirements.

Calpol Consent
To administer Calpol in an emergency situation, written permission is necessary in order to comply with insurance requirements. Please
sign below if you agree to the administration of calpol by the staff, if they think it necessary.
Please note that Cocoon will endeavour to make a courtesy telephone call to the parent before it is decided to administer a dose. Only
one dose of Calpol will be given. If a temperature persists, the parents will be contacted and asked to collect their child. Dosage: 2.5ml
– 5mls for babies under 12 months. 5mls - 10mls for children over 12months.
Signed:
X Parent/Guardian
Signed:
X Parent/Guardian
Signed:
X Nursery Manager Date:

Does your child suffer from any hearing and/or speech difficulties? □ YES □ NO
If YES, please state condition and provide written details of any requirements.

Permission for Nutrition

I/We hereby give my/our permission for: to consume ALL food items currently displayed on our menu.

(Dated / / /), and other food that Cocoon and/or its consultant nutritionist deem fit from time to time.

I/We are not aware of any conflicting allergies my/our child has.

Signed:
X Parent/Guardian
Signed:
X Parent/Guardian
Signed:
X Nursery Manager Date:

Does your child suffer from any FOOD allergies/ FOOD INTOLERANCES? □ YES □ NO
If YES, Please complete the Special Dietary Requirement form provided by the Branch Manager.
If attaching a Special Dietary Requirements Form with Child’s Booking Form, please tick box □
Does your child suffer from any NON FOOD allergies? □ YES □ NO

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 If YES, Please state allergy and provide written details of any requirements.

Does your child use ‘pet’ language for special comfort toys?

Name of siblings and/or close personal relationships in your child’s life:

Name: Relationship:

Name: Relationship:

Name: Relationship:

Name: Relationship:

Additional information that might help us to get to know your child better:

Accident and/or Emergency Authority

I/We hereby give my/our permission to the management of Cocoon Childcare / Operations Ltd to act on my/our behalf in case of
emergency or accident and to take such action as may be necessary for the welfare of my/our child.
Signed:
X Parent/Guardian
Signed:
X Parent/Guardian
Signed:
X Nursery Manager Date:
Photography, Facebook, Broadcast and Video Permission
I/We hereby give permission for my/our child to be photographed/broadcast or video recorded, under the supervision of Cocoon
Childcare / Operations Ltd. Terms and conditions are displayed on our website. This may vary from time to time.
Signed:
X Parent/Guardian
Signed:
X Parent/Guardian
Signed:
X Nursery Manager Date:
Model Release
I/We hereby give permission for my/our child to be photographed for the purpose of Cocoon Childcare promotional literature,
advertisements, Facebook, press, outdoor campaigns.

Signed:
X Parent/Guardian
Signed:
X Parent/Guardian
Signed:
X Nursery Manager Date:
Service Agreement
I agree that in the event of my/our child being withdrawn from the Cocoon Centre, two month’s notice or fees in lieu is required. I also
agree to all of the terms and conditions as outlined overleaf.

Signed:
X Parent/Guardian
Signed:
X Parent/Guardian
Signed:
X Nursery Manager Date:

Requested Days of Attendance: Mon □ Tue □ Wed □ Thur □ Fri □

Attendance Times Mon: Time in __________ Time Out__________

Tues: Time in __________ Time Out __________
Wed: Time in __________ Time Out __________
Thur: Time in __________ Time Out __________
Fri: Time in __________ Time Out __________

Lodge. Ref: ( OFFICE USE ONLY) Date: Registration No: Deposit Received: € Received By:

Manager to Complete- Payment method DD: Y / N

(Y: attach DD mandate, N: date parent asked to contact HO:Date: ____/____/____

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General Terms and Conditions

▪ The standard opening hours for a centre are 7.30am to 6.30pm, Monday to Friday.
▪ Opening hours are decided annually for each individual centre based on parents’ requirements and operating costs.
▪ Times may vary in each centre due to geographical location, parent’s requirements and any other relevant factors.
▪ Access to the centre can only be granted during opening hours for insurance purposes.
▪ All Centres are closed for the Christmas period each year. This is approximately from Christmas Eve until 2 nd/ 3rd of January. Appropriate notice of the exact closing and reopening
of the centre is provided by the 1 September of each year. Centres are also closed on Bank Holidays, Good Friday and St. Patrick’s Day.
▪ Parents are asked to be punctual at their collection times.
▪ Each child must be signed in and out every day using the role book provided.
▪ For safety reasons, it is requested that only a Parent/Guardian or Designated Person can collect a child. It is imperative that names and details of anyone who is authorised by the
parents to collect their child are clearly outlined on the child’s booking form. It is also required that parents contact the Centre in advance if anyone other than themselves are to
collect their child/children, even if they are a Designated Person.
▪ Parents are obliged to provide full details of any medical condition that their child may have, this includes allergies, dietary constraints or temporary illness.
▪ Should a child have any food or non-food allergies, suspected or otherwise, the centre must be informed in writing and in advance of the child taking up their place in the Centre,
or upon parents becoming aware of a child having developed an allergy, Parents must supply the Centre with a written action plan describing the care to be given to the child in
the event of a child having an allergic reaction, which should list all allergies, a list of specific symptoms, ways of preventing exposure to allergies, actions that should be taken if a
reaction occurs and any medication that have been prescribed or recommended by the child’s doctor. Any child with a life-threatening allergy must wear a medical alert bracelet
or necklace while in the Centre.
▪ Cocoon makes every attempt to identify ingredients that may cause allergic reactions for those food allergies. Every effort is made to instruct our food production staff on the
severity of food allergies. However, the risk of cross-contamination of foodstuffs remains and there is a possibility that manufacturers of commercial ingredients used by the Centre
could change the formulation and composition at any stage, without notice, and Parents concerned with food allergies must be aware of these risks. Cocoon Childcare / Operations
Limited (“Cocoon”) and its successors and assigns accepts no liability for adverse reactions to foods consumed or items a child may come in contact with while at the Centre.
▪ It is also required that parents list any previous operations or conditions their child has had in the past in case of emergency services being required.
▪ If a rash or any other suspected contagious condition is found on a child by a childcare worker or parent it is required that a diagnosis be made by a doctor immediately. This is to
prevent illness spreading amongst the children.
▪ Cocoon does not care for sick children. To avoid spreading illness to other children, please do not bring a sick child to the Centre. Any child with a suspected or diagnosed
contagious illness must have an accompanying doctor’s note on their return to the Centre certifying that they are fit to return. Further details regarding illness Policies and Procedures
are available in the Parents’ handbook.
▪ To prevent lost items, it is recommended that your child’s name be clearly marked on all clothing and personal belongings.
▪ Children should be dressed in casual, comfortable clothing while attending the Centre, e.g. Tracksuits, Leggings etc… Please remember children experience many activities including
art & crafts, baking, water play, meal times etc, so please dress them in play clothes.
▪ Parents are asked to provide a complete change of clothes at all times for their child, taking into consideration all seasonal changes.
▪ In the course of the development of any child, be aware that in the natural course of events they experience falls, cuts, bruises, etc. for which Cocoon cannot be held responsible.
▪ It is advisable that children do not bring personal toys to the Centre, these items can often be mislaid and cause upset at going-home time.
▪ COVID-19 Parental Agreement and Commencing Childcare Questionnaire must be completed and submitted to the centre management team 24-48 hours prior to your child
starting in the centre. Children are not permitted to attend the centre if they are displaying any signs or symptoms of COVID-19 as per the Government & HSE Guidelines
▪ Parents are fully responsible for informing the Centre of any changes to the child’s details immediately in writing.
▪ In the event of a national emergency or where urgent contact is required Cocoon may contact parents by text.

FEES , COMMENCEMENT & TERMINATION

▪ All schemes are subject to the Pobal terms and conditions in conjunction with Cocoon Childcare’s terms and conditions
▪ Fees are due for payment monthly in advance on the 28th day of the previous month by Direct Debit
▪ To book your child’s place, a deposit of €400 is required for fulltime, €200 for part time, €100 for National Childcare Subsidy IAS and €50 for ECCE only
▪ Referrals from TUSLA or a Public Health Nurse will require prior approval of payment of fees by the relevant party
▪ Payment terms for the parent’s element is by monthly Direct Debit. If your Direct Debit set up is not processed in time for collection of your first month’s fee you will be required to pay
that month’s fee by card.
▪ In circumstances where there are unpaid arrears on childcare fees, Cocoon reserves the right to add the arrears to the next month’s Direct Debit.
▪ All schemes require Pobal approval. Until this approval is received the application will not be deemed as processed.
▪ Inconsistent attendance of registered days of government funding schemes will result in Pobal removing funding for non-attended sessions. Cocoon will then collect the outstanding
fee by Direct Debit or alternative payment methods.
▪ A receipt will be issued to you for the fees you pay each month.
▪ Two month’s written notice is required to withdraw a child from a Cocoon centre.
▪ A completed “change in level of service form” is required should you need to increase or decrease (where applicable) your number of days. 1 months’ notice is required. All changes
take effect from the 1st of the month.
▪ Cocoon reserve the right to withdraw service for a child with a notice period deemed appropriate in circumstances at the discretion of the company. This can include immediate
withdrawal of services.
▪ The minimum care option provided by Cocoon under the ECCE scheme is 5 days. If attendance is not maintained at 5 days on an ongoing basis Cocoon reserve the right to cease
service.
▪ The refunding of any Deposit will be issued the last working day of the month when service ceases.
▪ A Deposit for ECCE children will be refunded where applicable
▪ If your child changes from part-time to full-time or vice-versa, the deposit must reflect that change.
▪ A separate deposit is required for each child, including siblings and relations.
▪ Fees are calculated from the commencement date stated by the parent on the booking form.
▪ Standard full-time care is for 10hours per day, any attendance for more than 10hours per day can incur additional fees
▪ Cancellations or any change to the commencement date without 2 months written notice will result in loss of deposit
▪ Changing commencement date may affect the availability of a place for your child.
▪ Delaying commencement date without 2 months written notice will result in fees being incurred from the original commencement date.
▪ In the event of a start date being changed, the booking deposit is non-refundable if the place held is then cancelled thereafter
▪ Fees and T&C’s are reviewed on a periodic basis. 1 Months’ notice will be provided in the event of any change
▪ A sibling discount of 10% off the eldest child applies when two children are attending 5, 4,3 Full Days or 5 Afterschool Days per week. A sibling discount of 8% off two eldest children
applies when 3 or more children attend on 5, 4, 3 Full Days or 5 Afterschool Days per week.
▪ Late payment of fees may result in a daily surcharge of €10.00. Continuous late payment of fees may result in a cessation of service.
▪ No allowance can be made for days/weeks lost due to illness or holiday.
▪ If your holidays coincide with the fee payment date of the first of every month, please ensure that your full month’s fees are paid in advance to prevent outstanding debts.
▪ This document does not constitute a contract until accepted and signed by an authorised Cocoon Head Office representative.
▪ Availability of all schemes will continue subject to availability in the relevant centre and on the condition all terms and conditions are met.
▪ In the unlikely event where Cocoon is forced to close due to unforeseen circumstances or individuals (staff/children) cannot attend, for example adverse weather conditions/public
health advice, our monthly fee will remain the same
▪ Please refer to ‘NCS Registration Agreement Form’ for NCS terms and conditions

Afterschool Terms & Conditions

Option 1—12-month Fee structure Sep to Aug inclusive-You cannot change to Option 2 during the 12 months. 2 months written notice required to cease service. Additional fees will be
due if transferring from Option 2 to Option 1 to cover the midterms and summer months. Breakfast club is complimentary No refund on fees if changing care option or ceasing service
during the 12 months. Care for school in service days or days outside planned holidays will only be facilitated based on centre availability
Option 2—10-month Fee Structure Sep to June inclusive -1 months written notice required to change care option. All changes take effect from the 1st of every month. During midterms
afternoon care ONLY is included in fee. Additional €20 per day is required for morning care during the midterms. Summer months revert to our standard rate. In the unlikely event that
organised transport is unavailable; it will be the parent’s responsibility to arrange alternative transport to and from school
The maximum age for children attending afterschool is 10 years old – we cannot accommodate children over this age
Where transport is provided for the afterschool service should this not available due to circumstances beyond our control, we will seek to notify parents as soon as possible. Parents are
responsible to arrange alternative transport arrangements for their children to/from school

I/We have read and accept the above terms and conditions in my/our capacity as guardian(s) of the child stated above:

Parent/Guardian Signature 1 X ________________________________________ Date: ______/_______/_______

Parent/Guardian Signature 2 X ________________________________________ Date: ______/_______/_______

Nursery Manager’s Signature X ________________________________________ Date: ______/_______/_______

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 Because…
you want the best for
your child.

HOW TO APPLY FOR A CHICK CODE FOR THE NATIONAL

CHILDCARE SCHEME SUBSIDY

You will need to register for a MyGovID account at

www.mygovid.ie
(A public service card will be required).

1. Once you have uploaded your information to apply for NCS on the MyGovID website you
should receive a ‘CHICK’ code.

2. Please give a screenshot of your NCS award details to your centre manager.

3. Once your NCS award is received & processed in our Head Office it will be uploaded onto
the NCS website.
Processing of NCS information may take up to a week in busy periods.

4. One processed you should then receive an email from the NCS to your MyGovID account
to confirm your care option details. (Parents are required to confirm these details in order
for your funding to be approved by NCS).

5. An application with Cocoon is not complete until you, the parent, has confirmed the
following details:

• Confirmed care options details (through NCS website).

• Completed Cocoon Booking & Registration forms.
• Completed Direct Debit mandate form.
• Deposit payment has been made.

6. Please note: It is not possible to backdate NCS funding as per NCS rules.

7. Once your NCS is calculated, you are required to complete an NCS Registration
agreement form under the NCS guidelines, which will require a parent’s signature.

Please note: If your Direct Debit has been processed before your NCS application has been
approved, the Government subsidy will be recognised in the subsequent Direct Debits.

Cocoon Team

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