BLUE HOUSE TIGONI

Enrolment form

The information contained on this form will be held securely to be used only for administrative purposes

Please enter your child’s details:

Surname/ Family Name: Child’s Name:

DD MM YYYY
Date of Birth:
Male: □ Female: □

Country of Birth/Nationality

Birth Certificate /
Date of Admission Home Address*
Passport/ID number

parent(s)/ legal guardian(s) or carer(s) information

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

Work Tel No: Work Tel No:

Mobile No: Mobile No:
Email Address: Email Address:

Relationship to Child: Relationship to Child:

*The address above must be the address where the child normally lives and with the adult who has parental responsibility.

Previous Care Information

Name of previous school/centre:

Address/Tel No.
Medical Information
Please indicate if your child has een diagnosed with any of the following

❑ Hearing Loss ❑ Sleep Problems ❑ Birth Defects

❑ Seizures
❑ Vision or Eye Problems
❑ Multiple Ear Infections
❑ Head Abnormalities
❑ Bipolar Disorder
❑ Chronic Skin Problems
❑ Hormone/ Growth
Problems
❑ Tics/ Movement Disorders
❑ Downs syndrome
❑ Frequent or Chronic
Headaches
❑ Asthma
❑ Anxiety
❑ Other Psychiatric Illnesses
❑ Chronic Stomach/Bowel Problems
❑ Allergies (environmental, seasonal)
❑ ADHD/ADD
❑ Depression
❑ Obsessive-Compulsive Disorder
❑ Kidney/Bladder/Genital Problems
❑ other physical illness

If indicated other, please explain

Has the learner received formal Autism Spectrum Disorder diagnosis? ☐ Yes ☐ No

Is the learner currently taking any medication/supplement?

Medication
Please provide information on medication/supplements that your child is taking

Medication/vitamin/supplement Purpose Side effects

Does the learner have any food allergies, follow any special diets or have special dietary needs? ☐ No ☐ Yes
If Yes, please explain

Is the learner covered by any medical cover? Please indicate

Note: If a learner should become seriously ill or sustain an injury requiring immediate treatment, supervising
staff may make the decision to seek Emergency Medical Services. Every effort will be made to establish
contact with parents prior to making this decision.

Parental Consent
The information above is to the best of my knowledge and by signing this document I formally give consent to Blue
House Tigoni, to use this information in administering care to my child.

Name……………………………………………………… Date……………………… Signature………………………………………..