CONTACT & PUPIL INFORMATION
ST THOMAS OF CANTERBURY CATHOLIC PRIMARY SCHOOL
TO BE RETURNED TO THE SCHOOL OFFICE FULLY COMPLETED
ANY CHANGES TO BE NOTIFIED IMMEDIATELY TO THE OFFICE
YEAR__________CLASS:________________________________________TEACHER: _____________________
(school to complete)
Surname of child (exactly as on birth certificate) _______________________________________________
Forename of child
_______________________________________________
Since completing our Yellow Supplementary Application Form have any of the details changed, eg, your home
address, telephone numbers, mobile numbers.
YES/NO
If yes, please record changes below, otherwise write ‘no change’.
Please give details of all persons who have parental responsibility and anyone else you wish to be
contacted in an emergency. Place them in the order that you wish for them to be contacted. Please add to
the list below any person you wish to collect your child at the end of the school day. If your child goes to
Cherubs or any other After School Club please add them below.
IN ALL CASES PLEASE PRINT
IN AN EMERGENCY WE WILL ALWAYS CONTACT THE PARENT IN THE FIRST INSTANCE.
Borough your child lives in: _______________________________
Priority
1
Title/Surname/Forename/Relationship
(Mum/Dad) exactly as on child’s birth certificate
Mrs/Ms/Miss/Mr
Work Phone/Email
Home Address
Work Number:
____________________________
Surname: ___________________________
Email address:
Forename: __________________________
____________________________
Mobile Number:
_________________________
Home Number: _________________________
2
(Mum/Dad) exactly as on child’s birth certificate
Home Address:
Mrs/Ms/Miss/Mr
Work Number:
Surname: ___________________________
___________________________
Email address:
Forename: __________________________
Mobile Number:
_________________________
____________________________
Home Number: _________________________
3
Home Address:
Relationship to child: ____________________
Mrs/Ms/Miss/Mr
Work Number:
Surname: ___________________________
____________________________
Forename: __________________________
Mobile Number:
_________________________
Email address:
____________________________
Home Number: _________________________
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Home Address:
Relationship to child: ____________________
Work Number:
Mrs/Ms/Miss/Mr
_____________________________
Surname: ___________________________
Email address:
Forename: __________________________
Mobile Number:
_________________________
____________________________
Home Number: _________________________
Home Address:
5
Relationship to child: ____________________
Mrs/Ms/Miss/Mr
Work Number:
Surname: ___________________________
____________________________
Forename: __________________________
Mobile Number:
_________________________
Email address:
____________________________
Home Number: _________________________
Home Address:
6
Relationship to child: ____________________
Mrs/Ms/Miss/Mr
Work Number:
Surname: ___________________________
____________________________
Forename: __________________________
Mobile Number:
_________________________
Email address:
____________________________
Home Number: _________________________
Travel Arrangements
Please tick
one box only.
Bicycle
Train
London Underground
Car/Van
Walk
Public Bus Service
Taxi
School Bus
Metro/Train/Light Rail
Car Share
Other
Route
Dietary Needs/Allergies
(if none, please write NONE)
Medical Practice:
(ie, doctor’s surgery)
Address and post code:
Telephone Number:
Medical Condition(s) (if none please write NONE)
___________________________________________________________________________________________
(asthma, allergies etc., any medication to be given at school to be left in school office
CLEARLY LABELLED WITH CHILD’S NAME AND INSTRUCTIONS
Name of medication: ________________________________________________Expiry Date:________________
I consent to my child being administered basic First Aid (ie, antiseptic wipes and plasters).
YES/NO
Medical Note(s)
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Did your child ever attend a school in the UK: YES/NO: If yes, has many schools has your child attended: ________
Please list below all schools attended starting with the school your child currently attends.
If no, has your child come from abroad: YES/NO If yes, when: ____________________________________________
PLEASE LIST ALL SCHOOLS/NURSERIES ATTENDED IN THE UK (if applicable).
Name, address and telephone number
of School
Start Date
End Date
CHILD’S ETHNICITY (Please tick the relevant box)
Black African
Black Caribbean
White UK
White European
Chinese
Indian
Other (please specify)
Reason for Leaving
Black Other
Bangladesh
Pakistan
Country of Origin
Mother
Father
HERITAGE LANGUAGE CHILD IS EXPOSED TO AT HOME
Heritage Language
Speaks
Reads
Writes
RESIDENCY STATUS OF THE FAMILY
Please tick as appropriate
a) British Nationality
b) Other Nationality with British Residency
c)
Refugee
d) Asylum Seeker
If c) or d) above please state country from which you are a refugee or an asylum seeker:
Special Educational needs _______________________________________________________
My child has been receiving:
Speech and Language Therapy
Portage (Portage is a home-visiting educational service for pre-school children with additional support needs and their families).
Yes/No
Yes/No
Signature Parent/Guardian: ____________________________________________________
Name: (please print)________________________________________ Dated: __________________________
GLOBAL/MASTER/CONTACT AND PUPIL INFORMATION /UPDATED 2 MAY 2013
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