Application

(Student Application)

(Student Name)

MaleFemale

(Address)

(Date of Birth)

(Age)

(Parents/Carers Details)

(Fathers Name)

(Mothers Name)

(Home contact number)

(Work contact number)

(Email address)

FatherMother

(Emergency Contact)

(Relationship)

(Address)

(Home Number)

(Work Number)

(Student Brief Medical History)

Does your child have any Allergies? *

Does your child have any special Dietary Needs? *

Name & Address of Doctor: *

Doctors Telephone Number: *

Language spoken at home: *

Brief madrasah history:*

Name of School/s Attended: *

Does your child have a statement/EHC plan of Special Educational Needs?

Please provide a brief summary of your child's needs?

Does your child require any personal care?

How is your child best supported?

Please be aware that in order to meet your child's needs fully we may require additional information e.g. EHC/Statement, Professional agency reports.

Ethnicity

Please use the space below for any other Additional Information that you think may be relevant

ALL INFORMATION GIVEN WILL BE DEALT IN STRICT CONFIDENCE AND UNDER THE DATA PROTECTION ACT