Admission of Pupils September 2012 Request for Admission to Durweston CE VA Primary School

Admission Number.. Date of Admission...

You must complete this form to enable your child to be allocated a school place. YOU MUST PRESENT YOUR CHILDS BIRTH CERTIFICATE WITH THIS FORM. Please complete your form using black ink and return it to the Headteacher of Durweston CE VA Primary School Please Note:If you have any difficulties in completing this form, the Headteacher will be pleased to help you. For September Reception Admissions only, please refer to the Dorset County Council information booklet Admissions in Dorset Schools: A Parents Guide a copy of which is normally provided with this form, but if not is available from the School Admissions Team at County Hall on (01305) 225052

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Name of child: Surname. Boy/Girl (please delete) Forename. Date of Birth.. Address.. Post Code.. Names & Dates of Birth of any brothers or sisters: Please indicate if your child has a statement of Special Educational Needs: YES/NO (Please delete) Does your child have a physical/medical disability which may require special access arrangements to the school? Previous school/nursery or playgroup and last date of attendance .. YES/NO (Please delete)

Information about the childs parents or others responsible for the child Who has parental responsibility for the child? (Please delete) Both Parents/Mother/Father/Other Person(s) Who does the child live with? (Please delete) Both Parents/Mother/Father/Other Person(s) Mothers Name. Fathers Name.. Address if different to above Address if different to above . . .Post Code Post Code. Tel No. .

Emergency Contact Information It is essential that we have information about 2 people, in addition to parents, whom we would be able to contact in an emergency. Mothers place of workTel. No.. Fathers place of work.Tel. No.. Other Contact 1 Name Address... Tel. No.. Relationship to Child... Other Contact 2 Name Address... Tel. No.. Relationship to Child...

Medical Information Name of Doctor Tel. No.. Surgery Allergies Is your child allergic to anything (e.g. bee stings, plasters, foods, drinks, etc) . . Does your child suffer, or have they been treated in the past for any of the following? If yes please give information about current treatment. Please give any other relevant medical information. Epilepsy YES/NO Asthma YES/NO Diabetes YES/NO Eczema YES/NO

Hearing Problems YES/NO Eyesight Problems YES/NO

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... Signature of parent/person with parental responsibility: .. Relationship to Child. Date.

PLEASE NOTE: Parents or those responsible for the child are asked to inform the school if any of the details provided above change at any time in the future. The details provided on the form are treated as Private & Confidential. They will be available to the School Office Staff for appropriate record keeping purposes. They will also be available to the Headteacher and the teaching staff who are involved with your child