Intro

Hackleton CEVA Primary School

Data Collection Form

The school and the Local Education Authority are required under Data Protection legislation to comply with essential good practice in respect of the information collected here and to manage it securely. The individuals who are the subject of the information or who have parental/guardian responsibility are generally entitled to see the information and are encouraged to help keep the information up to date. This information will be used for educational, welfare, planning or managerial purposes. For full details please ask the school for a copy of their Privacy Notice.

Email address *

Full Name *

Section 1 - Pupil Details

Surname *

Legal Surname (if different to above)

Forename *

Preferred Forename *

Middle Name *

Date of birth *

Please use format DD/MM/YYYY

Gender at birth *

Female

Male

Address including postcode *

Please provide the name and address of the previous school, pre-school or nursery attended *

If there is no previous school, preschool or nursery, please enter "None".

Please provide the name of any siblings that currently attend or have previously attended this school *

Enter "None" if this does not apply.

Is your child eligible for free school meals? *

Yes

I don't know

Does your child have any dietary requirements? *

Yes

Selecting Yes, please provide any dietary requirements. *

Please provide details of medical information.

Name of doctor *

Name and address of surgery *

Telephone number of surgery *

Brief details of any medical conditions *

Include any allergies to foods, medicines, plasters, etc.

Please provide any details of Special Educational Needs *

Is there an Education, Health and Care Plan in place? *

Yes

Is the child a Service Child? *

Yes

Is the child in Local Authority care? *

Yes

If yes, please enter name of local authority *

Ethnicity *

Home language *

Let us know the language most often spoken at home.

First language *

Let us know the language most often spoken by the child.

Nationality *

Religion *

Section 2 - Parent/Guardian Contact Details

Please give details of all persons that have parental responsibility. Email addresses will be used to send correspondence from school.

Parent/Guardian 1

Title *

Mr, Mrs, Miss, Doctor, Rev, etc.

Name *

Relationship to Child *

Parental Responsibilty *

Yes

Mobile number *

Home Tel Number

Work Tel Number

Email Address *

This email address will be used for all email correspondence.

Address and Postcode

Please enter your address and postcode here if it is different from that entered above.

Parent/Guardian 2

Title *

Mr, Mrs, Miss, Doctor, Rev, etc.

Name *

Relationship to Child *

Parental Responsibilty *

Yes

Mobile number *

Home Tel Number

Work Tel Number

Email Address *

This email address will be used for all email correspondence.

Address and Postcode

Please enter your address and postcode here if it is different from that entered above.

Emergency Contact (Priority 2)

Title *

Mr, Mrs, Miss, Doctor, Rev, etc.

Name *

Relationship to Child *

Parental Responsibilty *

Yes

Mobile number *

Home Tel Number

Work Tel Number

Email Address *

This email address will be used for all email correspondence.

Address and Postcode

Please enter your address and postcode here if it is different from that entered above.

Emergency Contact (Priority 3)

Title *

Mr, Mrs, Miss, Doctor, Rev, etc.

Name *

Relationship to Child *

Parental Responsibilty *

Yes

Mobile number *

Home Tel Number

Work Tel Number

Email Address *

This email address will be used for all email correspondence.

Address and Postcode

Please enter your address and postcode here if it is different from that entered above.

Signature of parent/guardian

Signature of parent/guardian *

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