Children’s Centres and Library Services

Registration Form (1A)

PLEASE WRITE CLEARLY AND IN CAPITAL LETTERS
About you (main parent/carer)
First and middle names (as appears on birth certificate) Ethnic background (please tick or ‘x’)
White British Any other Black background
First White Irish Chinese
Any other White background White and Black African
Middle Indian White and Black Caribbean
Bangladeshi White and Asian
Surname (as appears on birth/marriage certificate) Pakistani Any other Mixed background
Any other Asian background Traveller or Irish Heritage
Black African Gypsy/Roma
Black Caribbean Prefer not to say
Please specify if other ethnic group:

Gender Female Male Home language

Date of birth (DD/MM/YYYY) Relationship to child

Address Home

Mobile

Email

Postcode Are you a lone parent? Yes

If pregnant, when is baby due? (DD/MM/YYYY) Do you have a disability? If yes please specify

Yes

Your partner or other parent/carer

First and middle names (as appears on birth certificate) Ethnic background (please tick or ‘x’)
White British Any other Black background
First White Irish Chinese
Any other White background White and Black African
Middle Indian White and Black Caribbean
Bangladeshi White and Asian
Surname (as appears on birth/marriage certificate) Pakistani Any other Mixed background
Any other Asian background Traveller or Irish Heritage
Black African Gypsy/Roma
Black Caribbean Prefer not to say
Please specify if other ethnic group:

Gender Female Male Home language

Date of birth (DD/MM/YYYY) Relationship to child

Address (if different from above) Home

Mobile

Email

Postcode Are you a lone parent? Yes

If pregnant, when is baby due? (DD/MM/YYYY) Do you have a disability? If yes please specify

Yes

About your child/children

Children’s Centres Registration Form (1A) April 2014 PLEASE TURN OVER TO COMPLETE THE REST OF THE FORM Page 1 of 2
Children’s Centres and Library Services
Registration Form (1A)
First name Middle name Surname (as appears on birth certificate)
Child 1

Ethnic background
Date of birth (DD/MM/YYYY)
(select from table on page 1)
Disability/SEN?
Girl or boy
If yes, please specify
First name Middle name Surname (as appears on birth certificate)
Child 2

Ethnic background
Date of birth (DD/MM/YYYY)
(select from table on page 1)
Disability/SEN?
Girl or boy
If yes, please specify
First name Middle name Surname (as appears on birth certificate)
Child 3

Ethnic background
Date of birth (DD/MM/YYYY)
(select from table on page 1)
Disability/SEN?
Girl or boy
If yes, please specify
First name Middle name Surname (as appears on birth certificate)
Child 4

Ethnic background
Date of birth (DD/MM/YYYY)
(select from table on page 1)
Disability/SEN?
Girl or boy
If yes, please specify

Your consent under the Data Protection Act

I understand that the information that is recorded on this form will be stored electronically and used solely for the purpose of
providing services to me and my family. Any information regarding me and my family will be kept confidential and will not be
passed to organisations outside of Children's Centre partner agencies (with the exception of Redbridge Library Service
managed by Vision RCL and the London Libraries Consortium) without my consent, unless it is of a child protection nature,
in which case information will be shared with appropriate agencies. I understand that I can ask to see information held about
me and my child(ren) at any time. If you do not agree to this please tick here 

Registering with your local Children’s Centre also gives you and your child(ren) automatic membership to Redbridge Libraries
whereby your details will be shared with the Vision Redbridge Culture and Leisure Service (RCL). Redbridge Libraries upholds
the principle of Data Protection Act. The information supplied by you will be held on our database. Please understand that
you must comply with the library byelaws and regulations. In signing this registration form you certify that the details are
correct and accept responsibility for any items borrowed on your card and your children’s card(s).
 If you do not wish to access the library or you are already registered please tick here 
 If you do not wish to register with Children Centres please tick here 

Your signature
Main parent/carer Date signed

For office Date logged on Connects Main person ID Logged by Passed to CC/Vision
use only

Children’s Centres Registration Form (1A) April 2014 Page 2 of 2