karen@clubland-playscheme.com
0208 979 3100

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Registration form

Clubland Playscheme registration form amalgamation. Single child application with required fields activated

1 Registration

2 Permission

3 All about Me

4 Session Requests

5 Submit Registration

I am completing a:*
- New Registration
- Re Registration
For:*
- Permanent Sessions
- Ad hoc Sessions
- Holiday Club
Family Name:*
Family
School*
How many children do you need to register?*
- One
- Two
- Three
Child #1:
Preferred Name:*
Preferred
Date of Birth:*
Gender:*
- Male
- Female
Reception Child:*
- Yes
- No
Class:*
Child #2
Preferred Name:*
Preferred
Date of Birth:*
Gender:*
- Male
- Female
Reception Child:*
- Yes
- No
Class:*
Child #3
Preferred Name:*
Preferred
Date of Birth:*
Gender:*
- Male
- Female
Reception Child:*
- Yes
- No
Class:*
Collection Password:*
Home Address:*
Street Address Address Line 2 City / Town County Post Code
Name of Parent / Guardian:*
First Last
Relationship to Child:*
Daytime Tel:*
Evening Tel:*
Mobile Tel:*
Email*
Name of Parent / Guardian:
First Last
Relationship to Child:
Daytime Tel:
Evening Tel:
Mobile Tel:
Email
Name of Person/s who has Parental Responsibility:*
(All parents who can legally make decisions regarding this child)
Name of person who only has legal contact & not responsibility:
Are there any 'shared care' arrangements that may affect collection from Clubland:*
1st Alternative Emergency Contact:*
First Name Last Name
Daytime Tel:*
Mobile:*
Details of any Special Needs:*
Medical Conditions, Allergies and Medications:*
Dietary Needs:*
Doctors Name
Last Name
Doctors Tel:
Doctors Address:
Street Address Address Line 2 City / Town County Postal Code
Details of Cultural &/or Religious needs:*
Ethnicity: (Tick Applicable)*
- British
- Irish
- Other White
- White & Black Caribbean
- White & Black African
- White & Asian
- Other Mixed Background
- Indian
- Pakistani
- Bangladeshi
- Other Asian
- Caribbean
- African
- Other Black Background
- Chinese
- Any Other
Religion: (Tick Applicable)*
- C of E
- Catholic
- Other Christian
- Hindu
- Rastafarian Muslim
- Sikh
- Jewish
- Buddhist
Registration Information
Breakfast & Afterschool applications will be processed upon receipt of the relevant registration fee; Head office will call you to arrange payment.

Ad hoc sessions: £10 registration fee

Permanent Sessions: £25 (£15 refundable security fee, £10 non- refundable registration fee)
Please note that the security fee will only be refunded if you do not cancel the session once confirmed. As soon as your child commences Clubland 6 weeks’ notice in writing to cancel applies.
Your application will be processed upon receipt of the relevant registration fee, please call Head Office 02089793100 Monday – Friday, 9.30am -2pm to pay via chip & pin machine.

Permanent sessions = £15 (£15 security deposit will be returned in 1st invoice provided no cancellation of original sessions requested)
Terms & Conditions:*
I confirm that I have read the ‘terms and conditions’ of Clubland Playscheme Limited and agree to abide by them. Our full Policies & procedures are displayed at the Club house, or website: www.clubland-playscheme.com.

Please note there is a late fee payable for non- collection of children at closing time. Please see the website for details.
- I Agree

Save and Continue Later

To comply with the Data Protection Act 1998 and Ofsted regulations we require your permission for the following:
Child 1
My child to receive emergency treatment if necessary*
- Yes
- No
Child can watch appropriate 'PG' certificated films*
- Yes
- No
My child to go on local outings within walking distance*
(To include visits to local parks and playgrounds)
- Yes
- No
My child to receive Infant Paracetamol and/or Piriton as and when deemed necessary*
- Yes
- No
My child to travel on a company vehicle, in accordance with Ofsted regulations*
- Yes
- No
My child to travel in a member of staff's car, in compliance with Ofsted regulations*
- Yes
- No
I give permission for photographs to be taken of my child and that these photographs may be used for the following purposes:
- To share information with existing and prospective families. (Display board, brochures, banners, photobooks and newsletters)
- To promote Clubland via newspapers without their names
- To promote or share news about the childcare setting (Clubland website & Facebook page) no names
Sunscreen (provided by parent) to be applied as and when required by a member of staff*
- Yes
- No
I /we agree to abide by the Surrey Multi-agency information Sharing Protocol (MAISP) which is the over-arching protocol in a two-tier framework for information sharing in Surrey.*
More information at: http://surreyscb.procedures.org.uk/pkppq/policy-and-strategic-framework/information-sharing
- Yes
- No
Child 2
My child to receive emergency treatment if necessary*
- Yes
- No
Child can watch appropriate 'PG' certificated films*
- Yes
- No
My child to go on local outings within walking distance*
(To include visits to local parks and playgrounds)
- Yes
- No
My child to receive Infant Paracetamol and/or Piriton as and when deemed necessary*
- Yes
- No
My child to travel on a company vehicle, in accordance with Ofsted regulations*
- Yes
- No
My child to travel in a member of staff's car, in compliance with Ofsted regulations*
- Yes
- No
I give permission for photographs to be taken of my child and that these photographs may be used for the following purposes:
- To share information with existing and prospective families. (Display board, brochures, banners, photobooks and newsletters)
- To promote Clubland via newspapers without their names
- To promote or share news about the childcare setting (Clubland website & Facebook page) no names
Sunscreen (provided by parent) to be applied as and when required by a member of staff*
- Yes
- No
I /we agree to abide by the Surrey Multi-agency information Sharing Protocol (MAISP) which is the over-arching protocol in a two-tier framework for information sharing in Surrey.*
More information at: http://surreyscb.procedures.org.uk/pkppq/policy-and-strategic-framework/information-sharing
- Yes
- No
Child 3
My child to receive emergency treatment if necessary*
- Yes
- No
Child can watch appropriate 'PG' certificated films*
- Yes
- No
My child to go on local outings within walking distance*
(To include visits to local parks and playgrounds)
- Yes
- No
My child to receive Infant Paracetamol and/or Piriton as and when deemed necessary*
- Yes
- No
My child to travel on a company vehicle, in accordance with Ofsted regulations*
- Yes
- No
My child to travel in a member of staff's car, in compliance with Ofsted regulations*
- Yes
- No
I give permission for photographs to be taken of my child and that these photographs may be used for the following purposes:
- To share information with existing and prospective families. (Display board, brochures, banners, photobooks and newsletters)
- To promote Clubland via newspapers without their names
- To promote or share news about the childcare setting (Clubland website & Facebook page) no names
Sunscreen (provided by parent) to be applied as and when required by a member of staff*
- Yes
- No
I /we agree to abide by the Surrey Multi-agency information Sharing Protocol (MAISP) which is the over-arching protocol in a two-tier framework for information sharing in Surrey.*
More information at: http://surreyscb.procedures.org.uk/pkppq/policy-and-strategic-framework/information-sharing
- Yes
- No
Parent/Carer's Consent
I confirm that I have read and understood the information provided on this form and that I give consent for photographs of my children/ren to be used as indicated by me. For the purposes of GDPR I confirm that I am aware that my permission is not restricted to my child’s attendance at Clubland Playscheme Ltd and that I cannot withdraw my permission from a published photograph.
Parent / Carer's Name*
Prefix First Last
Email*
Permission Date

Save and Continue Later

Breakfast Club Days Requested - Child 1
NB: Breakfast club is only available from 7.15am at Claygate, Cranmere/St Pauls & Thames Ditton Infants. St Martin’s from 7.30am
Monday
Tuesday
Wednesday
Thursday
Friday
Breakfast Club Days Requested - Child 2
NB: Breakfast club is only available from 7.15am at Claygate, Cranmere/St Pauls & Thames Ditton Infants. St Martin’s from 7.30am
Monday
Tuesday
Wednesday
Thursday
Friday
Breakfast Club Days Requested - Child 3
NB: Breakfast club is only available from 7.15am at Claygate, Cranmere/St Pauls & Thames Ditton Infants. St Martin’s from 7.30am
Monday
Tuesday
Wednesday
Thursday
Friday
Afterschool Club Days Requested
Afterschool Days - Child 1
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
Afterschool Days - Child 2
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
Afterschool Days - Child 3
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
Start Date*
<hr/> I agree to comply with the Terms and Conditions as published by Clubland. Should I wish to permanently cancel the sessions which my child attends at Clubland, I agree to give six weeks notice in writing or pay six week's fees in lieu. Fees remain payable for periods of absence (holidays and sickness) as the child's place is kept open and staff and accumulated costs continue to accumulate and have to be met by the Playscheme.*
- I Agree
Session Terms & Conditions*
I agree to comply with the Terms and Condistions as published by Clubland. Should I wish to permamently cancel the sessions which my child attends at Clubland, I agree to give six weeks notice in writing or pay six week's fees in lieu. Fees remain payable for periods of absence (holidays and sickness) as the child's place is kept open and staff and accumulated costs continue to accumulate and have to be met by the Playscheme
- I Agree
Name of Parent / Guardian
First Last
Email
Date

Save and Continue Later

About Me - Child 1
My Name is:
First Last
I am aged:*
Please enter a value between 3 and 18.
I attend:*
School Name*
I live with:*
We live in a:*
I get upset by:*
Things I like to do & places I like to go......*
I like to eat:*
I dislike eating:*
Things I want to do at Clubland:*
My home language(s) is/are...*
Please upload a photo*
Accepted file types: jpg, gif, png, jpeg.
About Me - Child 2
My Name is:
First Last
I am aged:*
Please enter a value between 3 and 18.
I attend:*
School Name*
I live with:*
We live in a:*
I get upset by:*
Things I like to do & places I like to go......*
I like to eat:*
I dislike eating:*
Things I want to do at Clubland:*
My home language(s) is/are...*
Please upload a photo*
Accepted file types: jpg, gif, png, jpeg.
About Me - Child 3
My Name is:
First Last
I am aged:*
Please enter a value between 3 and 18.
I attend:*
School name*
I live with:*
We live in a:*
I get upset by:*
Things I like to do & places I like to go......*
I like to eat:*
I dislike eating:*
Things I want to do at Clubland:*
My home language(s) is/are...*
Please upload a photo*
Accepted file types: jpg, gif, png, jpeg.

Save and Continue Later

Thank you for taking to the time to complete our registration process, please submit to commit your registration.
Comments
This field is for validation purposes and should be left unchanged.

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About Us

Clubland was established in 1996 with the aim of providing a safe, supervised and stimulating child centered environment. It has always been our intention to ensure that this provision is inclusive, reliable and an affordable childcare service.

Contact Information

Address: Clubland Playscheme Limited
Darven House
Armfield Close
West Molesey
Surrey
KT8 2RT
Phone: 0208 979 3100.
Email: karen@clubland-playscheme.com

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© Copyright 2016 Clubland Playscheme

Home
Locations
How To Apply
Holiday Club
- Book Holiday Club
- FAQ’s for Holiday club
Parent’s Guide
Contact Us