Registration_child

Molenwater 4A | 4331 SB Middelburg | 0118-623652 | www.koozie.nl | info@koozie.nl

Parent 1

(this address will be used for correspondence)

Surname *

Initials *

Street name *

House phone *

Zip code *

Town *

Home phone

Mobile phone

E-mail *

Nationality *

Dutch Citizen service number (bsn)

Education

Date of birth *

Employer

Office phone

Parent 2

Surname

Initials

Street name

House phone

Zip code

Town

Home phone

Mobile phone

E-mail

Nationality

Dutch Citizen service number (bsn)

Education

Date of birth

Employer

Office phone

Child data

Surname *

First, middle, last name

Date of birth
(expected) *

Name child prefers to be called

Nationality

Dutch Citizen service number (bsn)

You agree that pictures of your child without name are published? *

yes

You agree that your child along with the othder children and the teaching assistant go to the park or visit the town

yes

Medical

Health insurance

Health insurance number

Family doctor

Phone number family doctor

Your child is or has been vaccinated in accordance with the applicable national vaccination program *

yes

There are peculiarities example of a medical nature or restriction, which we must keep in mind

Contact in case of an emergency (when parents unattainable)

Surname

Phone number/mobile number

Surname

Phone number/mobile number

Day care/After school care

Start *

Package selection *

Invoice by mail or postal mail? *

Which days do you wish to use child care?
0-4 year (day care) 4-13 year (after school care)

Monday

Supplementary

Breakfast (until 08:00 hrs)

Diner (from 17:00 hrs)

Supplementary

Before start school (07:30-08:30 hrs)

Before start school (07:30-08:30 hrs) including breakfast

Diner (from 17:00 hrs)

Tuesday

Supplementary

Breakfast (until 08:00 hrs)

Diner (from 17:00 hrs)

Supplementary

Before start school (07:30-08:30 hrs)

Before start school (07:30-08:30 hrs) including breakfast

Diner (from 17:00 hrs)

Wednesday

Supplementary

Breakfast (until 08:00 hrs)

Diner (from 17:00 hrs)

Supplementary

Before start school (07:30-08:30 hrs)

Before start school (07:30-08:30 hrs) including breakfast

Diner (from 17:00 hrs)

Thursday

Supplementary

Breakfast (until 08:00 hrs)

Diner (from 17:00 hrs)

Supplementary

Before start school (07:30-08:30 hrs)

Before start school (07:30-08:30 hrs) including breakfast

Diner (from 17:00 hrs)

Friday

Supplementary

Breakfast (until 08:00 hrs)

Diner (from 17:00 hrs)

Supplementary

Before start school (07:30-08:30 hrs)

Before start school (07:30-08:30 hrs) including breakfast

Diner (from 17:00 hrs)

Name of the primairy school

Other

Group

Legislation states that a child is placed in one fixed group of children. This group of children is called ‘basic group'. However, the law offers scope to deviate from this rule. With parent / caregiver permission, (extra) childcare may take place in a group other than the child's basic group, for example due to the (over or lower) occupation on the group or for educational reasons. The group members will inform you of the change of your child's basic group.
Do you agree that care of your child can take place in a second basic group? *

yes

Additional information

How did you find us?

Family/Friends		Our website		Google
Otherwise:

You agree to our terms and conditions, house rules and pedagogical policy (see website)*

Upon receipt and if placement is possible you will receive a copy of the notification, an invoice for the registration fee (€ 22,50) in case of a first notification concerns of the family and an offer of child care costs. We operate a mutual notice period of one month.

* = Input is required

Parent 1 (this address will be used for correspondence)

Parent 2

Child data

Medical

Contact in case of an emergency (when parents unattainable)

Day care/After school care

How did you find us?

Parent 1

(this address will be used for correspondence)