Scoil Náisiúnta Cill Damháin
Application for Enrolment
USE BLOCK CAPITALS PLEASE
Please include copy of birth and baptismal certificates.
Child’s Name: _________________________
Gender : Male
Female
(as on birth certificate)
Child’s P.P.S No: ____________________________________________________
Address: _____________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Date of Birth _________________________________________________________
Religion: ____________________________________________________________
Mother’s Name: ________________________ (Maiden Name)_______________
Address: _____________________________________________________________
Phone Number:
Mobile Number:
Work Number
_____________________________________________________________________
Occupation: __________________________________________________________
(for D.E.S. Statistics)
Father’s Name: _____________________________________________________
Address: _____________________________________________________________
Phone Number:
Mobile Number
Work Number
_____________________________________________________________________
Occupation: __________________________________________________________
Childminder:
Who will normally bring and collect your child from school:
Name: _________________________________________________________________
Address_________________________________________________________________
Phone Number
Mobile Number
Work Number
_____________________________________________________________________
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Deputy Contact (in case of neither parent being available)
Name ________________________________________________________________
Address: ______________________________________________________________
Phone Number
Mobile Number
Work Number
______________________________________________________________________
Relationship of deputy to your child_________________________________________
Family Doctor: ________________________________________________________
Address: ______________________________________________________________
Phone Number __________________________________________________________
Medical History:
Does your child suffer from any medical conditions we should be aware of ? Yes
No
(Allergies, chronic asthma etc…)___________________________________________
______________________________________________________________________
In the case of a medical emergency has the treating physician permission to give
emergency treatment to your child ?
YES
NO
Developmental History:
Has your child reached the ‘normal’ developmental milestones within ‘normal’ time
frame?
Has your child been assessed by any of the following:
Yes
Speech Therapist
No
Psychologist
Occupational Therapist
Other
If so please give details and include any reports.
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
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General Information:
Does your child have any special needs requirements ?
Yes
No
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Does your child require medication to be administered
in school.
Yes
________________________________________________
No
______________________________________________________________________
Number of children in family
Child’s place in family
Has your child attended play school/Montessori
Yes
No
Please state where and for how long:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Is your child normally right or left handed ?
_____________________________
Additional Information:
Is there any additional information you feel we should be aware of regarding your child
which would help us in our dealings with him/her ?
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
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I give my consent for the following:
1) For my child to take part in the R.S.E. programme.
2) For information regarding my child to be forwarded to
H.S.E. Immunisation Programme and D.E.S.
3) To Support the School’s Code of Behaviour.
4) For my child’s photograph to be used in the media and on the school’s
web-site should the opportunity arise (in accordance with Child
Protection Guidelines).
5) For information regarding my child to be uploaded on P.O.D.
( D.E.S. secure site). Please see pages 5 and 6 of this form.
Signed:
Date:
______________________
________________________
Signed: ________________________
Date:
________________________
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P. O. D.
The Department of Education and Skills has developed an electronic database of primary school
pupils called the Primary Online Database (POD) which will involve schools maintaining and
returning data on pupils to the Department at individual pupil level on a live system. The
database will allow the Department to evaluate progress and outcomes of pupils at primary
level, to validate school enrolment returns for grant payment and teacher allocation purposes,
to follow up on pupils who do not make the transfer from primary to post primary level and for
statistical reporting.
The database will hold data on all primary school pupils including their PPSN, First Name,
Surname, Name as per Birth Certificate, Mother's Birth Surname, Address, Date of Birth, Gender,
and Nationality. The database will record the class grouping and standard the pupil is enrolled
in. The database will also contain, on an optional basis, information on the pupil's religion and
on their ethnic or cultural background.
In order to assist with the gathering of data please complete page one and two of this form in
CAPITAL LETTERS and return to the school. This form will be retained by the primary school.
Class
Current Standard
Special Class
Pupil Forename:
PPSN of Pupil
Junior Infants
Senior Infants
First Class
Second Class
Third Class
Fourth Class
Fifth Class
Sixth Class
Pupil Surname:
____________________
Mother’s Birth
Surname________________
Pupil’s Date of Birth _________________
Pupil’s Gender: Male
Female
Birth Cert Forename (if different from name above)
Birth Cert Surname (if different from name above)
__________________________________________
Pupil Address
______
_____ _____
County
Nationality
(In the case of dual citizenship where Irish
is one, please specify both nationalities)
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The Department has consulted with the Data Protection Commissioner in relation to the collection of
individual pupil information for the Primary Online Database. Both religion and ethnic and cultural
background are considered sensitive personal data categories under Data Protection legislation.
Therefore, it is necessary for each pupil’s parent/guardian to identify their child’s religion and ethnic
background, and to consent for this information to be transferred to the Department of Education
and Skills. All other information held on POD was deemed by the Data Protection Commissioner as
non-sensitive personal data.
To which ethnic or cultural background group does your child belong (please tick one)?
(Categories based on the Census of Population)
White Irish
Irish Traveller
Any other White Background
Black or Black Irish - African
Roma
Black or Black Irish- Any other Black Background
Asian or Asian Irish - Chinese
Asian or Asian Irish – Any other Asian Background
Other (inc. mixed background)
What is your child’s religion?
Roman Catholic
Church of Ireland (Anglican)
Presbyterian
Methodist, Wesleyan
(Islamic)
Jewish
Muslim
Orthodox
(Greek, Coptic, Russian)
Apostolic or Pentecostal
Hindu
Buddhist
Jehovah's Witness
Lutheran
Atheist
Baptist
Agnostic
Christian Religion
(not further defined)
Protestant
Evangelical
Other Religions
No Religion
I consent for the sensitive personal data in the two questions above to be stored on the Primary Online
Database (POD) and transferred to the Department of Education and Skills and any special schools my
child may transfer to during the course of their time in primary school.
Signed: ___________________________
Date: ____________________________
Parent/Guardian
Please complete this form and return to your primary school. For further information on POD please go
to the Department of Education and Skills’ website www.education.ie
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