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Coronavirus Childcare Form

Step 1 of 3

Child and Parent Details

Details Child 1 Child 2 Child 3 Child 4
Child's Name
Child's DOB
Medication /
Food Allergies
School /
Setting Name






Step 2 of 3

Week 1 of 7

Please provide the dates for the weeks specified in line with your rota/shift pattern of when childcare would be required?

w/b - 01/06/2020 Monday Tuesday Wednesday Thursday Friday
Drop off time:
Collection time:
Breakfast Required:
Lunch Required:
Step 2 of 3

Week 2 of 7

Please provide the dates for the weeks specified in line with your rota/shift pattern of when childcare would be required?

w/b
08/06/2020
Monday Tuesday Wednesday Thursday Friday
Drop off time:
Collection time:
Breakfast Required:
Lunch Required:
Step 2 of 3

Week 3 of 7

Please provide the dates for the weeks specified in line with your rota/shift pattern of when childcare would be required?

w/b
15/06/2020
Monday Tuesday Wednesday Thursday Friday
Drop off time:
Collection time:
Breakfast Required:
Lunch Required:
Step 2 of 3

Week 4 of 7

Please provide the dates for the weeks specified in line with your rota/shift pattern of when childcare would be required?

w/b
22/06/2020
Monday Tuesday Wednesday Thursday Friday
Drop off time:
Collection time:
Breakfast Required:
Lunch Required:
Step 2 of 3

Week 5 of 7

Please provide the dates for the weeks specified in line with your rota/shift pattern of when childcare would be required?

w/b
29/06/2020
Monday Tuesday Wednesday Thursday Friday
Drop off time:
Collection time:
Breakfast Required:
Lunch Required:
Step 2 of 3

Week 6 of 7

Please provide the dates for the weeks specified in line with your rota/shift pattern of when childcare would be required?

w/b
06/07/2020
Monday Tuesday Wednesday Thursday Friday
Drop off time:
Collection time:
Breakfast Required:
Lunch Required:
Step 2 of 3

Week 7 of 7

Please provide the dates for the weeks specified in line with your rota/shift pattern of when childcare would be required?

w/b
13/07/2020
Monday Tuesday Wednesday Thursday Friday
Drop off time:
Collection time:
Breakfast Required:
Lunch Required:
Step 3 of 3

Summary

Details Child 1 Child 2 Child 3 Child 4
Child's Name
Child's DOB
Medication /
Food Allergies
School /
Setting Name

Preferred Provision :


Parent 1 Key Worker (name) :

Parent 1 Occupation as key worker criteria :

Parent 1 - What critical tasks do you undertake that make your work vital at this time? (If emergency services or medical please just state your place of work) :

Parent 1 Emergency Contact number :


Parent 2 Key Worker (name) :

Parent 2 Occupation as key worker criteria :

Parent 2 - What critical tasks do you undertake that make your work vital at this time? (If emergency services or medical please just state your place of work) :

Parent 2 Emergency Contact number :


Emergency Contact Name :

Emergency Contact Number :


Does your child currently receive approved transport from the local authority to access the home school? :

Please provide your home address :

Could you please confirm the reasons/need for the transport :


Please write any additional information the parent/carer would like to communicate to staff (this is to minimise the time of face to face contact): :


w/b
Monday Tuesday Wednesday Thursday Friday
Drop off time:
Collection time:
Breakfast Required:
Lunch Required:

w/b
Monday Tuesday Wednesday Thursday Friday
Drop off time:
Collection time:
Breakfast Required:
Lunch Required:

w/b
Monday Tuesday Wednesday Thursday Friday
Drop off time:
Collection time:
Breakfast Required:
Lunch Required:

w/b
Monday Tuesday Wednesday Thursday Friday
Drop off time:
Collection time:
Breakfast Required:
Lunch Required:

w/b
Monday Tuesday Wednesday Thursday Friday
Drop off time:
Collection time:
Breakfast Required:
Lunch Required:

w/b
Monday Tuesday Wednesday Thursday Friday
Drop off time:
Collection time:
Breakfast Required:
Lunch Required:

w/b
Monday Tuesday Wednesday Thursday Friday
Drop off time:
Collection time:
Breakfast Required:
Lunch Required:


As parents/carers we understand that:-

The childcare facility may be withdrawn or changed at anytime depending on government direction.

Schools will not function as a school but have been repurposed for emergency childcare cover and that my child will not be taught, have lessons or follow a school timetable.

Children of school age may not be cared for in their own classroom or by their own teacher or by the same person all the time. My child may be with children of all school ages depending on how the facility will be organised. My child does not need to wear uniform and I will provide an additional set of clothes in a bag. There will be no charge for breakfast or dinner.

Whenever possible my child will be kept  at a distance of 2 metres away from all others.

We/I will stand 2 metres away from staff other members of the public whenever possible during drop off and collection.

We/I must provide proof that BOTH parents reach key worker criteria.

We/I must provide proof of BOTH parents work schedules on a weekly basis to take into account different shift patterns.

Hub/provider will refuse admission of my child if the strict criteria is not adhered to.

We/I will endeavour to minimise the time my child spends at the facility to reduce the risk of infection and safeguard themselves and others. (this may mean picking up and dropping off at different times and days  - complete a time schedule and order breakfast and dinner if required)

Any person being verbally abusive will be asked to leave the premises.  

We/I understand the facility is open between 8am and 6pm on weekdays. However, these times may vary in preschool settings depending on the provider.

We/I as a parent have made every effort to find home based childcare and have absolutely no alternative.

We/I understand that keeping my child at home is the best option for the prevention of becoming infected.

We/I understand that there is a risk that my child could become infected within the school building.

In the event that a member of the household is displaying symptoms of the Coronavirus, I must telephone the school to inform them. All members of my household will self-isolate for 14 days after symptoms appear and understand that we cannot access childcare during isolation. We will continue to restart the 14 day rule should other members within the household become infected.

No person displaying the symptoms should come onto school premises even if it is to drop off.

If staff become ill they will self-isolate for 14 days.

If numbers of staff reduce because of illness the facility will close

The hub could be redirected to an alternative facility in the future depending on demand and government guidance.

These are unprecedented circumstances that are changing daily, information will be shared as quickly as possible. We, as parents, will be as understanding and cooperative as possible in order to safeguard our family’s communities and to essentially save lives.

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