KIDS opvang G.O.B. Nederland

Regio Putten en omstreken

 

 

Naam                              :                                                                                                             

 

Voornaam                      :                                                                                                             

 

Geboorte datum            :                                                                                                   

 

Adres                              :                                                                                                             

 

Postcode en woonplaats    :                                                                                                       

 

Telefoon                         :                                                                                                             

 

 

Bent u WA verzekerd?                                                                                            ja / nee

 

 

Heeft u een ongevallenverzekering?                                                               ja / nee

 

 

Omschrijving samenstelling gezin:

 

inwonende kinderen:                                geb.datum:        j\m       school:

1.                                                                                                                                                   

2.                                                                                                                                                   

3.                                                                                                                                                   

4.                                                                                                                                                   

 

 

Voor welke kinderen zoekt u opvang:

                                                                                                                                             

                                                                                                                                             

 

 

Wanneer moet de opvang beginnen?

                                                                                                                                             

                                                                                                                                             

 

 

Maakt u momenteel gebruik van een andere vorm van kinderopvang?

Zo ja, welke vorm en voor welk kind?

                                                                                                                                             

                                                                                                                                             

 

 

Minimum aantal uren dat opvang wordt gevraagd?                                           

Maximum aantal uren dat opvang wordt gevraagd?                                           

Dagen en tijden waarvoor opvang wordt gevraagd:

Maandag            van                                              t/m                                    

Dinsdag              van                                              t/m                                    

Woensdag          van                                              t/m                                    

Donderdag         van                                              t/m                                    

Vrijdag               van                                              t/m                                    

Zaterdag             van                                              t/m                                    

Zondag                van                                              t /m                                   

 

 

De moeder is werkzaam bij een bedrijf, instelling of studerende?      ja / nee

naam bedrijf/instelling   :                                                                                                           

adres                                 :                                                                                                           

postcode en plaats          :                                                                                                           

telefoon                            :                                                                                                           

contactpersoon                :                                                                                                           

C.A.O.                               :                                                                                                           

 

De vader is werkzaam bij een bedrijf/instelling of studerende?           ja / nee

naam bedrijf/instelling   :                                                                                                           

adres                                 :                                                                                                           

postcode en plaats          :                                                                                                           

telefoon                            :                                                                                                           

contactpersoon                :                                                                                                           

C.A.O.                               :                                                                                                           

 

Opmerkingen:

                                                                                                                                             

                                                                                                                                             

 

 

 

Datum  :                                                    naam  :                                                                        

 

 

 

 

 

 

Handtekening :