THE nursery school
The Old Priory
Mdina
Tel: 21454115
Fax: 21450372
Registration number
Date received
Date Acknowledged
Application for the term starting Month ___________Year__________
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01 Child's First Name _________________________
02 Parent's Names & Surname _________________________
03 Address (line 1) _________________________
Address (line 2) _________________________
Address (line 3) _________________________
Postcode ________________________
04 Telephone Numbers Home ____________________
Mobile ___________________
Office __________________
Pager ____________________
05 Child's Date Of Birth ___________________________
06 Child's Nationality ___________________________
07 Child's Religious Denomination _____________________________
08 Has your child been vaccinated against:
Tetanus Yes No
Polio Yes No
Whooping Caugh Yes No
Diphtheria Yes No
09 Family Doctor
Telephone Numbers Home _____________________
Other _____________________
10 Transport:
Please indicate pick-up and drop-off points:
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Please note that whilst it is the Nursery school's policy to offer a door to door service such a service may not be possible from all areas and locations.
11 General: Kindly list below any other information which you consider necessary for the Nursery School to know about to ensure the well being of your child.
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Parents Signature Date
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