ࡱ> ] 7bjbj  x-\x-\'F 4h|P| cZ( ' ' 'bbbbbbb$eehnb)%l '))bb...)Vb.)b..n\XZ2`D*X](vbb0 c]Dh*hP2`h2`D ''.d(t(# ' ' 'bb- ' ' ' c))))h ' ' ' ' ' ' ' ' ' > :  ADMISSION FORM [CONFIDENTIAL] School:  PUPIL DETAILS     ADDRESS DETAILS  If the childs residence at the present address (whether living with parents or any other person) is not permanent, please state the reason and probable duration of the stay, and give the name and address of the person with whom the child normally resides:  It would be very helpful to have available the names and dates of birth of any older or younger siblings who are currently attending or have attended this school, or are likely to join this school at a later date.ForenameSurnameDate of Birth CONTACTS Parent/Carer 1: Mr / Mrs / Miss / Ms / Other ___________ Forename: Surname:Parent/Carer 2: Mr / Mrs / Miss / Ms / Other ___________ Forename: Surname:Relationship to child: Do you have parental responsibility? ( Yes ( No Relationship to child: Do you have parental responsibility? ( Yes ( No Address (if different to pupil): Apartment: ___________________________ Apartment: ______________________ House Name: _________________________ House Name: ______________________ House Number: _______________________ House Number: ______________________ Street: ____________________________________ District: ___________________________________ Town/City: ________________________________ Town: ______________________ Postcode: _________________________________ Address (if different to pupil): Apartment: ___________________________ House Name: _________________________ House Number: _______________________ Street: ___________________________________ District: __________________________________ Town/City: ________________________________ Postcode: _________________________________Please tick the box against your main telephone numberPlease tick the box against your main telephone numberTel Nos:Home: (Tel Nos:Home: (Mobile: (Mobile: (Work: (Work: (e-mail:e-mail:Please attach a copy of any court orders relating to your child. Please tick if attached ( OTHERS WITH PARENTAL RESPONSIBILITY AS DEFINED BY CHILDREN ACT 1989 Parental responsibility may be shared between a number of people beyond the childs natural parents, for example those with a Parental Responsibility Order. Married parents have equal parental responsibility; on separation or divorce both parents continue to have responsibility. In such circumstances the school will forward copies of school reports, etc. to the separated parent if requested. Please give details below.Mr / Mrs / Miss / Ms / Other ___________ Forename: _____________________ Surname: ________________________ Relationship to child: _________________________________Address: Apartment: ___________________________ House Name: _________________________ House Number: _______________________Street: _______________________________ District: ______________________________ Town/City: ___________________________ Postcode: ____________________________Tel Nos:Home:Work:Mobile:e-mail: Is the child resident with foster parents: Yes ( No ( If yes; which Authority is financially responsible for maintenance? ________________________________________ From time to time it may be necessary to contact someone during the school day, e.g. in the case of a childs sickness. Please list below (in order of preference) the details of any person(s), including parents, who we can contact on such an occasion. No.NameRelationship to the child (Parent, Grandparent, relative, neighbour etc)Known to the child as? e.g. Gramps, NanaDaytime telephone number 1Mr / Mrs / Miss / Ms / Other _________ Forename: ___________ Surname: _____________2Mr / Mrs / Miss / Ms / Other _________ Forename: ___________ Surname: _____________3Mr / Mrs / Miss / Ms / Other _________ Forename: ___________ Surname: _____________4Mr / Mrs / Miss / Ms / Other _________ Forename: ___________ Surname: _____________ MEDICAL INFORMATION Knowledge about your childrens health is vital if we are to help them to achieve their potential educationally. Would you please supply the following medical information about your child. This information will only be shared with relevant professionals within education and health who need to know in order to support your child in school. If you wish to discuss your childs health confidentially, please contact the School Nurse. DIETARY NEEDS( Artificial colour allergy( Gluten Free( Kosher food only( No dairy produce( No nuts of any type/quantity( No pork( Ramadan( Seafood allergy( Vegetarian( Halal( Other (please specify) ______________________ MEDICAL PRACTICESurgery Name:Surgery Telephone Number: MEDICAL INFORMATIONDoes your child suffer from?( Asthma( Epilepsy( DiabetesBowel or bladder problemsEczemaAny other medical condition _____________________Do you consider your child to have a disability? Yes / No If Yes, please select all that apply from the list below. A child is considered to have a disability if their parent indicates substantial and/or long term difficulties with one or more of the areas listed below. Please exclude difficulties that you would expect for a child of their age.Mobility Hand Function Personal CareEating and drinkingMedicationIncontinenceCommunicationLearning HearingVisionBehaviourConsciousness e.g. seizuresASD/AspergersPalliative care needsOther Disability/Health problem __________________Does your child attend any medical clinics? - Yes / No If Yes, please give details in the box belowIf you have ticked any of the above boxes, please give further details below:- If your child is on regular medication, does it need to be given during school hours? Yes / No If Yes please discuss with the Headteacher. ETHNIC/CULTURAL INFORMATION The Department for Education (DfE) has asked for the collection of the following information for all pupils.ETHNICITYWhite British Irish Traveller of Irish Heritage Gypsy/Roma Any other white background Asian or Asian British Indian Pakistani Bangladeshi Any other Asian background Mixed White & Black Caribbean White & Black African White & Asian Any other mixed background Black or Black British Caribbean African Any other Black background Other Chinese Any other ethnic group I do not wish an ethnic background category to be recorded Childs Country of Birth ______________________ Childs Nationality ___________________________ FIRST LANGUAGE The language to which your child was first exposed in their early childhood and which they continue to use or be exposed to at home or in your community.ArabicBengaliChinese CantoneseChinese MandarinDutchEnglishFrenchGermanGreekGujaratiHindiItalianJapanesePanjabi (Gurmukhi)Panjabi (Mirpuri)PashtoPolishPortugueseShonaSpanishSwahiliTagalog/FilipinoTamilThaiTurkishUrduVietnameseOther (Please specify) ____________________________________I do not wish a first language to be recorded RELIGIONAnglicanBaptistBuddhistChristianChurch of EnglandHinduJehovahs WitnessJewishMethodistMormonMuslimPlymouth BrethrenQuakerRoman CatholicSikhUnited Reform ChurchNo ReligionI do not wish a religion to be recordedOther (Please specify) _________________ ADDITIONAL INFORMATION MEALSEntitled to Free MealsGoes HomeSandwichesPaid School MealsTRAVEL TO SCHOOL - Please tick your childs usual main mode of travel. If the journey to school involves more than one mode of travel tick the mode used for the greatest part, by distance, of the journey.WalkCycleCar/VanCar Share (with a child/children from a different household)Public service busDedicated school bus/coachBus (type not known)TaxiTrainLondon UndergroundMetro/Tram/Light RailOtherFOR SCHOOL USE ONLYLA provided transportRoute Service Children in Education Indicator are one or both parents Service personnel, serving in regular military units of any of the HM Forces, or in the Armed Forces of another nation and stationed in England and exercising parental care and responsibility? ( Yes ( No ( I do not wish to answer this question PREVIOUS SCHOOL HISTORY School, Pre-School or Nursery NameTown/CityDate of arrival (dd/mm/yy)Date of leaving (dd/mm/yy)Reason for LeavingFor pupils being admitted into the Reception Year only, please include the number of terms spent in pre-school education, where known:- ________________________terms. PARENTAL DECLARATION DATA PROTECTION STATEMENT: The purpose of this form is to collect data for further processing within the school/Local Authority/Health Authority systems. The data will be processed in accordance with the purposes notified by the school/Local Authority/Health Authority to the Data Protection Commissioner's office and are subject to the Data Protection Act. The information given will be entered onto a computer and will form part of the Schools database. Your signature on this form implies your consent for the school/Local Authority/Health Authority to process the data.DECLARATION OF PERSON WITH LEGAL RESPONSIBILITY: I declare the above information to be correct to the best of my knowledge at the time of completion. I agree to notify the school of any change in my childs circumstances. Signed: __________________________________________ Date: ________________________       Version 10.0 Page  PAGE 4 of  NUMPAGES 4 Buckinghamshire County Council All schools are required by law to keep on record details of children admitted. We should therefore be grateful if you would complete this form in BLOCK CAPITALS and hand it into the school office when your child is admitted. Your childs birth certificate/passport should be presented for copying and placing on file at the time of your childs admission to primary education. Legal Surname: As shown on Birth Certificate/Passport Legal Forename: As shown on Birth Certificate/Passport Middle name(s): Preferred Forename: Preferred Surname: Date of birth: Gender: Male / Female (delete as applicable) Home Other - Term Time / Overseas / Other Apartment: ______________________ Apartment: ______________________ House Name: ______________________ House Name: ______________________ House Number: ______________________ House Number: ______________________ Street: ______________________ Street: ______________________ District: ______________________ District: ______________________ Town/City: ______________________ Town/City: ______________________ Postcode: ______________________ Postcode: ______________________ Reason: _______________________________ Dates Applicable: ______________________ Forename: _______________________________ Surname: ________________________________ Address: ______________________________________________________________________________ ______________________________________________________________________________ FOR SCHOOL USE ONLY Registration Group: ______________________ House: ______________________ * NC Year Group: ______________________ * Year Taught in: ______________________ * Enrolment Status: ______________________ Boarder Status: ______________________ * Admission Date: ______________________ Admission No: ______________________ UPN: ______________________ Attendance mode: ______________________ Birth Certificate/Passport seen and copied: ( (Infant/Combined Schools only) *required fields for SIMS  *12345:;IJLijklտնխՈs_UI5&jh!LCJOJQJUmHnHuhlCJOJQJaJh"CJOJQJ&jhNB2CJOJQJUmHnHu hF*hF*CJOJQJ^JaJh"hNB2h"5CJ OJQJaJ )jhn^V5CJOJQJUmHnHuh>5OJQJh?5OJQJh"5CJOJQJh"5CJOJQJh"5OJQJjh6PCJ`OJQJU&jh6PCJ`OJQJUmHnHu 46789:;IJijkmnorsvwxygdF*lnopqsuwxyY ] w ѽvkvXO;&h3fh3f5CJOJQJ\^JaJh"5OJQJ%jh"5OJQJUmHnHuh4Fr5CJOJQJh"5CJOJQJhlhF*CJOJQJaJ*jhQCJOJQJUmHnHsH uh"hF*hlh"CJ OJQJaJ &jhF*CJOJQJUmHnHu*jhF*CJOJQJUmHnHsH uhlh"CJOJQJaJh"CJOJQJ {{{$Ifqkd%$$Ifl `''   0 4 lap yt}B <$Ifgd}B w <$Ifgd)*7ckd&$$Ifl #`''0 4 layt}Bw x }}}$<$Ifa$gdTtkd$'$$Ifl4`''   0'4 laf4p yt}Bw x    ( ) * R ǾǾǾym]Q]ymh#<CJOJQJaJhBch#<5CJOJQJaJhMCJOJQJaJhh"CJOJQJaJhM5CJOJQJaJhhY;5CJOJQJaJh>ch"CJaJh"h"CJOJQJh3f5OJQJh3f5CJOJQJh3h3f5CJOJQJaJh3fh3fh3fCJaJh3f5CJOJQJ\^J l___ <<$IfgdTkd'$$IflF& `'   0'    4 lapyt}B l___ <<$IfgdTkd~($$IflF& `'   0'    4 lapyt}B l___ <<$IfgdTkd+)$$IflF& `'   0'    4 lapyt}B  T ljhh[[QQ <<$If <<$IfgdY;kd)$$IflF& `'   0'    4 lapyt}BR S T ] | պ~qgqgaO@hY;5CJOJQJ^JaJ#hhY;5CJOJQJ^JaJ hCJhh5CJ jrhh5CJh5CJaJhh5CJaJhY;CJaJhhY;CJaJhhCJaJh"5OJQJhh"CJOJQJaJh#<CJOJQJaJhBch#<5CJOJQJaJhMCJOJQJaJhhMCJOJQJaJ 8 }}pp <<$IfgdY; <<$IfgdY;tkdw*$$Ifl4     0Q(0     4 laf4   * + 7 8 9 A E W Y Z |    ; < Z _ b e g    źujhRT5CJOJQJhm5CJOJQJhQ5CJOJQJhBc5CJOJQJho 5CJOJQJh#<5CJ\aJhh"5CJ\aJhh"CJaJhY;5OJQJhhCJOJQJ^J" jrhhCJOJQJ^J hhCJOJQJ^JaJ%8 9 Z : h mmmmmmbW <$Ifgdj <$Ifgdo  3ad$Ifgdo  <$IfgdItkd*$$Ifl4     0Q(0     4 laf4 -/0QTvy #(*-SUZ[_´¦zzodoohRT5CJOJQJhQ5CJOJQJhtEI5CJOJQJhm5CJOJQJhBc5CJOJQJho 5CJOJQJh"CJOJQJ^JaJh#<CJOJQJ^JaJ hh"CJOJQJ^JaJ#hh"5CJOJQJ^JaJh>ch"CJOJQJaJh"CJOJQJaJ"0Y3`abY $Ifgdjtkd+$$Ifl4     0Q(0     4 laf4 <$Ifgdo  3ad$Ifgdo  <$Ifgdj _`ah%*hijklsǷǷttk\ttk\hh#<CJOJQJaJh#<5OJQJ jrhICJOJQJhICJOJQJ\aJhh#<CJOJQJ\aJhh#<5CJOJQJaJh 5OJQJhh CJOJQJ\aJh CJOJQJ\aJhIh CJOJQJ\aJh"5OJQJ#hho 5CJOJQJ^JaJ %j|ykd,$$Ifl4     0Q(0     4 laf4yt# $IfgdjjklbYYYY $Ifgdjkd,$$Ifl4     \Q(,0     4 laf4=>bYYYY $Ifgdjkd_-$$Ifl4     \Q(  ,0     4 laf4;<=>C@ȸȯ~qf[WMCM9h>cCJOJQJh|2CJOJQJh"CJOJQJh"h;h"CJaJh"5CJOJQJ jrh;CJOJQJhY;5CJOJQJh"5CJOJQJhI5OJQJ"hhI5CJOJQJ\aJh#<5OJQJhh#<5CJOJQJaJhh#<CJOJQJ\aJ jrhICJOJQJhICJOJQJ\aJh#<CJOJQJ\aJbUU <<$Ifgdjkd.$$Ifl4     \Q(  ,0     4 laf4~akdu/$$Ifl((04 laytI <<$Ifvkd.$$Ifl4     0Q(  0     4 laf4@X}pp <<$Ifgdo nkd/$$Ifl ((   0 (4 lap <$If <<$If 5>WXn;<ein߰ynynynycyXycycynyhm5CJOJQJhRT5CJOJQJhBc5CJOJQJhI5CJOJQJhhICJaJ#ho h"5CJOJQJ^JaJhtEI5CJOJQJ^JaJ#ho ho 5CJOJQJ^JaJhtEI5CJOJQJaJho ho 5CJOJQJaJho CJOJQJaJh"5OJQJh"5CJOJQJ<eyyyyyyl <<$Ifgdm 3ad<$Ifgdm <<$Ifgdmdkd0$$Ifl4     ((0     (4 laf4ytI 89CIJKNS}|l|\|LhtEIh3f6CJOJQJaJh_Fh3f6CJOJQJaJh_Fh_F5CJOJQJaJh_Fh3f5CJOJQJaJhf.5CJOJQJh hf. h"6 h"CJ jrh;h"h;h"CJaJhtEI5OJQJhtEICJOJQJ\hhtEI5CJOJQJaJhI5OJQJ#hhI5CJOJQJ^JaJxx $Ifgd@I$Ifwkd1$$Ifl4     0H(0     (4 laf4ytmK2,$<$If 9r kd1$$Ifl4     r  (pp 0     (4 laf4p2yttEIKv <$IfgdQrkd2$$Ifl((  04 l` ap <<$If&8QRrdd$<$Ifa$gd3f$<$Ifa$gdT$<$Ifa$gdY;qkdv3$$Ifl((   0(4 lap ytm %&78QRSTU{|²yk_PD;D/DhfPCJOJQJaJh3f5OJQJh3fCJOJQJaJhf.h3fCJOJQJaJhmCJOJQJaJh3f6CJOJQJ\]h_Fh3f5CJOJQJaJh3f6CJOJQJ\]h3f5CJOJQJh_Fhm5CJOJQJaJh_Fh3f5CJOJQJaJhtEIh3f5CJOJQJaJhtEIh3f6CJOJQJaJhtEIhm6CJOJQJaJhtEI6CJOJQJaJRSU|:,! 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