Form from: St Michael and All Angels

Childs' Details

Forename

Middle Name

Surname

Chosen Name (if different to forename)

Gender

Date of Birth

Year Group

Home Address and Postcode

Child's mobile number (if has own phone)

Any siblings within school or pre-school?

Please name siblings within school and/or pre-school and their current year group


Emergency Contacts

Please give details of all persons (minimum of three) you wish us to contact in an emergency and place them in the priority order that you wish for them to be contacted. In line with Calderdale Safeguarding Advice please ensure that one of the contacts does not live at the same address as the child.

Parental Responsibility

All people with lawful parental responsibility must be included below. 

Emergency Contact Priority 1

Priority 1 Name

Priority 1 Relationship to child

Priority 1 Mobile Number

Priority 1 Work Telephone Number

Priority 1 Home Telephone Number

Priority 1 Email address

Priority 1 Home address (if different to child)

Does Priority 1 have Parental Responsibility for the child?

Can the child stay overnight with Priority 1

Additional Notes Priority 1


Emergency Contact Priority 2

Priority 2 Name

Priority 2 Relationship to child

Priority 2 Mobile Number

Priority 2 Work Number

Priority 2 Home Telephone Number

Priority 2 Email Address

Priority 2 Home address (if different)

Does Priority 2 have Parental Responsibility for the child?

Can the child stay overnight with Priority 2

Additional Notes Priority 2


Emergency Contact Priority 3

Priority 3 Name

Priority 3 Relationship to child

Priority 3 Mobile Number

Priority 3 Work Number

Priority 3 Home Telephone Number

Priority 3 Email Address

Priority 3 Home address (if different)

Does Priority 3 have Parental Responsibility for the child?

Can the child stay overnight with Priority 3

Additional Notes Priority 3

Would you like to add a further contact (Priority 4)?

Priority 4 Name

Priority 4 Relationship to child

Priority 4 Mobile Number

Priority 4 Work Number

Priority 4 Home Telephone Number

Priority 4 Email Address

Priority 4 Home address (if different)

Does Priority 4 have Parental Responsibility for the child?

Can the child stay overnight with Priority 4

Additional Notes Priority 4


Does the child have any key professionals (e.g. for a child who is CP or CLA-Social Worker/Virtual School or YOT worker)

Name

Agency

Telephone

Additional Telephone

Professional's Relationship to child

Email


Travel Arrangements

Please select the method of transport used to travel to and from school

Please detail route walked


Medical and Dietary Information

Name of Medical Practice, address and telephone number

Any medical conditions?

Please detail medical conditions

Any disabilities?

Please detail disabilities

Any allergies?

Please detail allergies

Any dietary requirements?

Please detail dietary requirements


Ethnicity

Language spoken at home

Religion

Data Protection Act 1998: The school is registered under the Data Protection Act for holding personal data. The school has a duty to protect this information and to keep it up to date. The school is required to share some of the data with the Education Authority and with the Department for Education.

Parent/Carer completing this form please sign below

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