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Paras

SAMPLE: Thank you for submitting your form.

SAMPLE: This is some information you might need.

More information here?

Your Details

Parent/Primary Carer's:

E-mail Address*:

Telephone Number*:

First Name*:

Last Name*:

Relationship to the Child/Children*:

Your Address*:

Postcode*:

Ethnic Origin*:

Main language spoken at home*:

Where did you hear about Doorstep Library:

Children

Please list the first names of all your children aged 0-4 years

Child Name*	Date of Birth*	Gender*	Special Educational Needs and Disabilities
				Delete
Add Child

Age-range	I'd like to attend*
0-3 years
4-5 years

Which weekly sessions are you interested in attending?

The sessions are scheduled to run every Wednesday during term time. Please select all of the times you are interested in attending.

Session	I'd like to attend*
Wednesdays at 10:30: 0-4 years
Wednesdays at 17:30: 0-4 years
If you can’t attend any of these times, please tell us which days and times would work better for you? We can't promise, but we will then in touch if we can change the time and day in the future:

Please read and tick the following statements

I understand that I must be present on-screen with my children at all times during Online Read and Play Groups*

I understand that Doorstep Library volunteers and staff cannot be responsible for the physical safety of my child*

I understand that Doorstep Library staff might ring me during a session if they are concerned about the safety of my child*

I consent to Doorstep Library safely recording some of my personal details (e.g. address, children’s names, ages and any other information necessary for the provision of their service).*

I understand that I can withdraw this consent at any time by contacting Doorstep Library on 02088701476.*

I understand Doorstep Library will not share my personal details with anyone (unless they are concerned about me or my children’s safety).*

Other sample field types

Stacked Radios:

Option 1

Option 2

Stacked Radios with ticks (like checkbox):

Option 1

Option 2

Stacked Radios with ticks (like checkbox) - with Other option:

Role 1

Other

Multi-select (in a row):

Multi-select (full width):

Some sort of assessment rating:

	Excellent	Good	Fair	Poor
Question 1	Excellent	Good	Fair	Poor
Question 2	Excellent	Good	Fair	Poor
Question 3	Excellent	Good	Fair	Poor

Review and Submit

Please check all details above are correct, then use the button to submit your registration.

Sub-notes?