Registration Form Privacy Protection ‘Thelvomaton you provide on this lox wl el be proces forthe purpose fo which it hasbeen gen an wile elton 3 database. Ts wl alow so send Jou ater elted nian the te, We ono 0 trade or of ths nlrmaton others andl rina wae te oration o proces you eppaton to ive your chi ated to Rugby School. This maybe shred ith th party conan for ths purpose ony. We may 0 We your ema tess nar you about ‘amon opportuni that maybe once ‘The Sches Data Protection Ply can be found onthe Schools websteat wnrugbyscheecouklsbewschol- poe Pss contac the formation Security Ofer {inosecuriyOraghyscool nto an 01788 SS6353 for quis bout how your daa ed. Myo do nok wh ore ay farther srt rm Rhy Shoal a rv plese cma sorsornenigeyschoolnet, (ease speak othe Had of your chs school belore submitting this frm; when we receve It we wil sume that we may wt tothe school or a epot) ‘CHILD'S DETAILS: Please complete in BLOCK letters using BLACK INK. Surname Date of Birth ! / Male |_| Female First Names Preferred Name Religion _ Nationality _Frst Language (if not English) Year of entry Enury Level 13+(] 16+(] Boarding or Day Preferred House Present School School Address Name of Head Mr / Mrs / Ms Email GENERAL HEALTH - All questions must be answered, Does the child have any known medical condition or health problems or allergies? vesC] nol Are ony treatments required? ves nol Has your son/daughter ever suflered from an eating asorder? vest] nol] May the chill be unable to play a full part in the games and sporting cucu ofthe Schoof? ves] Noll Ifyou have answered Yes to any of the above, up-to-date details willbe requested later by the School Medical Officer. SPECIAL CIRCUMSTANCES - All questions must be answered, Does the child have any learning difficulty, special educational need, disability corbehavioura/emotional and/or socal difficulty? ves Nol] ‘Are the parents separated or divorced? vesC Nol] i yes, should both parents receive malings? ves] Nol] Does any person named inthis form expect to change address during the next 12 months? ves Nol] ‘ne there any Court Orders in relation to the child, for example ast parental responsibilty, reathrcs Cnkac, profits cig specckxues or pains payers? ves] nol In relation to the parents, is either parent an undischarged bankrupt or subject to an indvtvalvluntry agreement? vest nol Will your child require sponsorship from the School in order to obtain a Visa to study in the United kingdom at this School? yes] Nol] Ifyou have answered yes, please provide o colour copy ofthe child’ passport.Father's/Legal Guardian's details (it home address differs from father’s please indicate which Is child's address) ‘Mother’s/Legal Guardian's details Title: Title: Surname: Surname: First Name(s): First Name(s): Home Address: Home Address: Postcode: Postcode: Home Tel No: Home Tel No: Mobile No: Mobile No: Home E-mail Home E-mail Connection to Rugby School (if any) ‘Occupation: Name of Employer: Business Address: Connection to Rugby School (if any) Occupation: Name of Employer: Business Address: Business Tel No. 1 parents live abroad please give details below ofthe guardian in the UK Business Tel No. Tite: Home Tel No. Surname: Mobile No.: First Name(s) E-Mail: Home Address: DECLARATION I/we request that our child named above is registered as a prospective pupil Please note that if your child is offered a place at Rugby School and you choose to accept this, then all persons with parental responsibility will be expected to accept the place and will be jointly and severally liable for the payment of, fees. Any bursary application will be assessed against all persons with parental responsibility. Signature of Parent/Legal Guardian (1): Names in fll (1): Relationship to child (1) Date: @ @y @ ‘A cheque for the non-refundable registration fee of £150, payable to ‘Rugby Schoo’, should be enclosed together with this completed form and retumed to: Admissions Registrar, Admissions Office, Rugby School, Temple House, 1 Barby Road, Rugby CV22 SDW. Should you wish to pay the registration fee (£150 plus bank charges) by bank transfer, our bank details are as follows: ‘Bank: National Westminster Bank - Rugby Branch - Account Number: 49415689 - Sort Code: 54-41-00 Account Name: Governing Body of Rugby School - Swift Code: NWBKGB2L IBAN ref: G892NWBK54410049415689 Please quote the pupil's name as a reference