Application form after school program (4 till 12 years old)

APPLICATION FORM – AFTER SCHOOL PROGRAM (4 – 12)
Information about your child
First name: ________________________________
Last name: _________________________________
gender: O boy
O girl
BSN (social security number): *
Date of birth: ___________________
School: _____________________________________
School times: ____________________________________________________________
Is a child in your family currently attending KOK kinderopvang? O yes O no
Does your child need special care?
O yes O no
Would you like us to contact you to do a tour?
O yes O no
Preference
0 After school care including school holidays
(4 years - 12 years)
0 After school care without school holidays
(4 years - 12 years)
0 Before school care
(4 years - 12 years)
0 Early opening (12:00 – 15:15)
(4 years - 12 years)
0 Before/After school care for children with special needs (4 years - 12 years)
Preferred location (if available):
0
BSO Spetters, Jacob Catsstraat 25, Katwijk
0
BSO De Kleine Horizon, Mgr. Bekkersstraat 1B, Katwijk
0 Before school care
0 After school care
0
BSO De Duintoppers, Prinses Irenelaan 49, Katwijk
0 Before school care
0 After school care
0
Sport-BSO De Quickers, Laan van Nieuw Zuid 25, Katwijk.
0
BSO De Vrije Vogels, Schimmelpenninckstraat 2, Katwijk
0 Before school care
0 After school care
0
BSO Buitengewoon, Valkenhorst 2, Valkenburg ZH
0 Before school care (schools: De Dubbelburg en De Burcht)
0 After school care (schools: De Dubbelburg, De Burcht en de Otto Baron)
0
Sport-BSO Valken, Duyfraklaan 7, Valkenburg ZH
(schools: De Dubbelburg, De Burcht and Otto Baron)
0 BSO Rakkers, Luit Katlaan 7, Valkenburg ZH
0 Before school care
0 After school care
0
BSO Starkids, Nassaulaan 1, Rijnsburg
(schools situated in Rijnsburg)
0 Before school care
0 After school care
BB/rev.1/ 14
Starting date
Day: ______ Month: __________________ Year: ______
Before School Care
0 monday morning
0 tuesday morning
0 wednesday morning
0 thursday morning
0 friday morning
Early
Opening
After School Care
0 monday
0 tuesday
0 wednesday
0 thursday
0 friday
(12.00 – 15.15)
0 friday
Information about the parent(s)
Last name/Initials mrs./mr.
Last name/Initials mrs./mr.
Parent 1 _________________________________
Parent 2 _____________________________
Date of birth ____________________________ *
Date of birth _______________________*
BSN:*
BSN:*
Address ________________________________
Postal code ______________________________
City ___________________________
Home phone number __________________________
Mobile phone number ________________________
Mobile phone number __________________
Work phone number __________________________
Work phone number ___________________
Emergency phone number _______________________
E-mail address ________________________________________________________________
You will receive a monthly invoice at this e-mail address.
Doctor’s name _______________________________
To advertise effectively we would like to know how you found us:
_______________________________________________________________
Comments ________________________________________________________________
___________________________________________________________________________
Date:
Signature:
BB/rev.1/ 14

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