Common use of Custodial Statement Clause in Contracts

Custodial Statement. Are there any custodial arrangements concerning your child? If YES, please give details of any custodial arrangements or court orders (a copy of any court order is required) Person/s who cannot pick up your child: Name: Name: Name: Name: Name: Phone: Name of medical centre: Illness/allergies: Is your child up-to-date with immunisations? Tick One Yes No (Please provide verification of all immunisations) For staff: Immunisation records sighted and details recorded: Tick One Yes No

Custodial Statement. Are there any custodial arrangements concerning your child? If YES, please give details of any custodial arrangements or court orders (a copy of any court order is required) Person/s who cannot pick up your child: Name: Name: Name: Name: Name: Phone: Name of medical centre: Any changes to this form must be signed and dated by the parent/guardian. Illness/allergies: Is your child up-to-date with immunisations? Copy to be provided. Tick One Yes No (Please provide verification of all immunisations) For staff: Immunisation records sighted and details recorded: Tick One Yes No

Custodial Statement. Are there any custodial arrangements concerning your child? If YES, please give details of any custodial arrangements or court orders (a copy of any court order is required) Person/s who cannot c annot pick up your child: Name: Name: Name: Name: Name: Phone: Name of medical centre: Illness/allergies: Is your child up-to-date with immunisations? Tick One Yes YesOne No (Please provide verification of all immunisations) For staff: Immunisation records sighted and details recorded: Tick One Yes YesOne No

Custodial Statement. Are there any custodial arrangements concerning your child? If YES, please give details of any custodial arrangements or court orders (a copy of any court order is required) Person/s who cannot pick up your child: Name: Name: Name: Name: Doctor’s Name: Medical Centre: Phone: Name of medical centre: Illness/allergies: No Is your child up-to-date with immunisations? Tick One Yes No (Please provide verification of all immunisations) For staff: Immunisation records sighted and details recorded: Tick One Yes No

Custodial Statement. Are there any custodial arrangements concerning your child? If YES, please give details of any custodial arrangements or court orders (a copy of any court order is required) Person/s who cannot pick up your child: Name: Name: Name: Name: Name: Phone: Name of medical centre: Illness/allergies: No Is your child up-to-date with immunisations? Tick One Yes No (Please provide verification of all immunisations- Declined: ( / / ) For staff- Complete 15 months: Immunisation records sighted and details recorded( / / ) - Complete 4 years: Tick One Yes No( / / )

Custodial Statement. Are there any custodial arrangements concerning your child? If YES, please give details of any custodial arrangements or court orders (a copy of any court order is required) Person/s who cannot pick up your child: Name: Name: Name: Name: Doctor’s Name: Medical Centre: Phone: Name of medical centre: Illness/allergies: Is your child up-to-date with immunisations? Tick One Yes No (Please provide verification of all immunisations) For staff: Immunisation records sighted and details recorded: Tick One Yes No