Data Collection Form

Childs' Details

Forename

Middle Name

Surname

Legal Surname (if different to above)

Chosen Name (if different to forename)

Gender

Date of Birth

Home Address and Postcode

Child's mobile number (if has own phone)

Any siblings within school or pre-school?

Yes No

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

Other settings attended (if applicable)

Password

Proof of DOB seen by member of staff

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 - Same home address as child?

Priority 1 Home address (if different to child)

Does Priority 1 have Parental Responsibility for the child?

Yes No

Can the child stay overnight with Priority 1

Yes No

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 - Same home address as child?

Priority 2 Home address (if different)

Does Priority 2 have Parental Responsibility for the child?

Yes No

Can the child stay overnight with Priority 2

Yes No

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 - Same home address as child?

Priority 3 Home address (if different)

Does Priority 3 have Parental Responsibility for the child?

Yes No

Can the child stay overnight with Priority 3

Yes No

Additional Notes Priority 3

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

Yes No

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 - Same home address as child?

Priority 4 Home address (if different)

Does Priority 4 have Parental Responsibility for the child?

Yes No

Can the child stay overnight with Priority 4

Yes No

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)

Yes No

Name

Agency

Telephone

Additional Telephone

Professional's Relationship to child

Email

Travel Arrangements

Please detail route walked

Medical and Dietary Information

Name of Medical Practice, address and telephone number

Any medical conditions?

Yes No

Please detail medical conditions

Any disabilities?

Yes No

Please detail disabilities

Any allergies?

Yes No

Please detail allergies

Any dietary requirements?

Yes No

Please detail dietary requirements

Language spoken at home

English Urdu Arabic

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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