Hackney residents should complete this form only. If you live outside Hackney you must complete the form available from the Borough or County Council within whose area you live. Please carefully read the guidance notes on the last page before completing the f orm. Completed forms must be returned to the address shown at the end of the form, by 25th October 2013. If this form is received after the national closing date of 31st October 2013, it will be treated as a late application. There is the easier option of applying on-line, go to:

1. Child’s Details
Child’s First Name(s) Child’s Date of Birth Surname/ Last Name






Child’s Home Address

Post code: Is the above address: Permanent? Is the address: Social housing Private landlord Yes No Living with a relative

Owner occupier

Please provide end date of tenancy agreement ........./........./..........

(This must be the address where the child normally lives between Monday and Friday and where the child benefit is received. If this is different from the parent/carer address, please give reasons for this. If parents share custody, this must be stated and both addresses shown).

Primary School (Please also give address if school is outside Hackney)


2. Parent’s/Carer’s Details
Parent/Carer 1 Title (Please circle)
Surname Mr Mrs Miss Ms Other First name

Relationship to Child e.g father, mother

State address if different

(If address is different from child’s home address provide reasons for this)
Home Tel no. Mobile Tel E-mail Address

Parent/Carer 2 Title (Please circle)




Ms Other

First name

Surname Home Tel no. Mobile Tel

Relationship to Child e.g father, mother E-mail Address

Please turn over

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3. Secondary School Preferences
Please write the name of up to SIX schools which you wish to apply to. You must list the schools in the order you prefer them. You should include all state-funded schools, academies and free schools for which you wish to apply, including any schools which are outside of Hackney. You should include the details of any sibling (brother or sister) who is currently attending the school below. Applications for private fee-paying schools must be made separately, direct to the school.

Name of secondary school
Preference 1

Borough or County in which school is located

First name, surname and date of birth of any sibling(s) already attending the school

Medical/social reasons

Tick box - if documents are attached for medical/social reasons
Preference 2

Tick box - if documents are attached for medical/social reasons
Preference 3

Tick box - if documents are attached for medical/social reasons
Preference 4

Tick box - if documents are attached for medical/social reasons
Preference 5

Tick box - if documents are attached for medical/social reasons
Preference 6

Tick box - if documents are attached for medical/social reasons

Staff child - Children of staff who work at the school /academy fulltime with at least two year’s continuous employment by the Academy or where the Academy reasonably considers a member of staff has been recruited for a position for which there is a demonstrable skill shortage.
Name of staff School / academy name Designation / Role Start date

4. Other information
Reasons for preferences - Please give the reasons below for your application including any relevant background information, these
might include religious, philosophical or any other reasons.

Please continue on a separate sheet if necessary. Exceptional Medical, Social or Other Grounds
These might include religious, philosophical or any other reasons. If you think that there are exceptional medical or social reasons why your child should attend a particular school, you must provide professionally supported evidence with this application form. It is very important that you check the admission criteria of each school for which you are applying to see if priority of admission can be given on this basis.

Please continue on a separate sheet if necessary.

5. Children in Care/Subject to a Child Protection Plan –
Is this child Looked After by a Local Authority If yes, please complete below: Local authority Social worker name

This includes all looked after children and children who were previously looked after, and are now subject to an adoption, residence, or special guardianship order.
Is this child subject to a Child Protection Plan (CPP)? Contact number



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6. Declaration and Signature of Parent/Carer
I wish to apply for a place at each of the schools named in Section 3, and I have listed these schools in my order of preference. I certify that I am the person with parental responsibility for the child named above who lives in the Borough of Hackney, and that the information given is true to the best of my knowledge and belief. I understand that any false or deliberately misleading information given on this form and/or supporting information may render this application invalid, or lead to the offer of a place being withdrawn.

Parent’s/Carer’s Signature




Information supplied will be used for registered purposes under the Data Protection Act 1998.

Checklist: Before returning this form, please ensure that you have: Read the accompanying notes and the secondary school admissions brochure ‘Hackney’s Secondary Schools 2014 Admissions Guide for Parents’ and/or the guide for the borough or county council in which each school for which you are applying is located. Checked that your child’s address is within the Borough of Hackney. Completed all relevant sections of this form. Enclosed any supporting evidence (e.g. a letter from the family doctor/hospital consultant in support of any medical or social claim) Attached the relevant proofs of address (if you have changed address in the last year we may request further evidence):

The original council Tax Bill for Year 2013/2014 or the original letter for Housing Benefit entitlement An original utility bill received within the last two months (Gas, Electricity or Landline phone) Completed supplementary forms MUST BE SENT DIRECTLY TO THE SCHOOL(S) CONCERNED. Please check the admission arrangements for each school for which you are applying to see if a supplementary form is required.

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This form should not be completed in respect of a child who has a Statement of Special Educational Needs All Hackney residents must complete this form. The national closing date is 31 October 2013, we would prefer all th completed forms returned to Hackney Learning Trust by 25 October 2013. Hackney Learning Trust will be operating an Equal Preference system in accordance with the Pan-London Admissions System, The Pan - London Schools Admissions System is used by all 33 London boroughs together with neighbouring Counties. All your preferences will get considered at the same time, regardless of its rank and whether the school is in another local authority. Section 1 – Child’s Details All sections must be completed. Section 2 – Parent’s/Carer’s Details Please ensure that the names of all responsible adults/carers are recorded on the form for the secondary school to approach. Please note that when parents live separately, the application must be based on one address where the child normally lives between Monday and Friday and where the child benefit is received. You should provide a letter of explanation as to the living/care arrangements of your child if the address is different to the address that is normally used. Hackney Learning Trust will withdraw offers of a place if it has been proven that false or misleading information has been provided. Section 3 – Secondary School Preferences You are entitled to name up to six secondary schools anywhere in London as your expressed preferences on this form (except for private fee paying schools). Please ensure that you complete all the boxes that are applicable to each preference. Sibling Connection - It is important that you state if your child already has a brother or sister including step siblings, (they must be living in the same household/ address between Monday to Friday) attending the preference school, as this can give your child priority for admission. Medical/Social reasons - Special consideration can be given to children who have a particular medical or social need. This will need to be demonstrated by providing professionally supported documentation, and explains why this means your child can only attend a particular school. These documents should be attached to this form or sent to us by Monday 6th January 2014. Children of staff working at a school – Some schools, as part of their criteria give priority to children of staff working in their school. You will need to provide the member of staff details (who is the parent of the child) on the form in order to be considered under this priority. If applying to Cardinal Pole Catholic, Lubavitch Girls Senior Girls Jewish, The Urswick CE, Our Lady’s Covent Catholic and Yesodey Hatorah Girls Jewish Schools you must obtain a supplementary form for religious commitment. The supplementary form must be completed by the Priest/Vicar/Pastor/Rabbi and is available directly from either Hackney Learning Trust or the secondary schools. Completed supplementary forms must be sent directly to the school(s) concerned. Section 4 – Other information Please give reasons for preferences Please write a supporting statement if you are considering to apply for medical/social priority and include any relevant documents. Please note not all schools have this criterion. Section 5 – Children in Care/Subject to a Child Protection If you are a Foster Carer, looking after a child who is in public care, this must be indicated on the form. Children in this category will be given priority of admission to the community schools in Hackney in accordance with the criteria for admission. If previously looked after proof of this must be supplied.
Please return this form to: Admissions Team, Hackney Learning Trust, 1 Reading Lane, E8 1GQ Contact number: 020 8820 7501/7247

RECEIPT Receipt of application: Your application has been received by: ...................................................................................................... (To be signed by the Admissions officer receiving the form) Name of Child ______________________________________ Date of Birth / / Page 4

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