Devon Children's Centres - Membership Form

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The information you have given on this form will be held confidentially on a secure database and used and stored in line with our Privacy Notice and Data Retention Policy which can be found here.

By completing this form you are indicating that you wish to register with a Children’s Centre and you are happy for us to hold and process the information contained on the form below.

Name - Parent/Carer 1 *

First Name	*
Surname	*

Date of birth *

	DD/MM/YYYY

Address details *

First line of address	*
Town	*
Postcode	*
Contact Number	*

Please provide us with your email address *

Due date if Pregnant

	DD/MM/YYYY

Other information. Please select if appropriate to you and add to comments

Disability/Special Needs
Any Special Requirements?

Comments:

Name - Parent/Carer 1 *

Date of birth *

Address details *

Please provide us with your email address *

Relationship to child *

Do you have parental responsibility? *

Ethnic Group

Due date if Pregnant

Employment information *

Other information. Please select if appropriate to you and add to comments

Are you a member of the armed forces?

MAIN CARER ONLY - Is anybody in paid employment in your household? *

Do you have a partner that lives with you? *