2015/16
Dear Parents
NEW STUDENT ADMISSION FORM – ST JOHN’S MARLBOROUGH
FORENAMESURNAME
YEARREG GRP
Now that you have accepted the place offered to your child at an Excalibur Academy it is necessary for you to complete our Admission Form.
In order to ensure that our records are as accurate and up-to-date as possible, please complete all relevant fields on the application form. Please note it is essential that your postcode is correctly shown, and that you include your child’s ethnicity and main language – this is a Department for Education requirement.
Each medical condition is to be listed separately, with an additional space for you to add further information in the DETAILS/MEDICATION box where necessary, ie:“Carries Ventolin Inhaler”. I would like to mention here that if your child has a health problem, particularly in the case of asthma, it is essential that you provide us with as much information as possible and indicate how severe or frequent the attacks are likely to be. Please indicate on the form if your child currently has a Care Plan.
Insofar as the Emergency Contact is concerned, please note that in the event of an emergency the Academy will make every effort to contact a child’s parents either at home or at work. Only if these attempts fail will we get in touch with an emergency contact that is not directly responsible for your child.
Please note that all generic correspondence from St John’s (generic letters, notices, newsletters etc) as well as student reports will be sent home electronically via SIMs InTouch/SIMS Learning Gateway and not in paper form via students or the postal service. The new system will allow us to improve our contact between home and St John’s as the need for instant communication becomes greater. Therefore it is essential that you include a primary email address where indicated on the form. If you do not wish to receive correspondence in this way please confirm your intention to opt out by completing the relevant section on the Declaration Sheet at the end of this form.
It is Excalibur Academies Trust policy to direct all communications (reports, letters etc) to the person with whom the child normally lives. Please be aware that an absent parent/carer has the right to see this information if they ask. If the child is the subject of a Court Order of any kind please notify us immediately (Note: we will ask to see such Orders as are in force.)
I should be grateful if you could sign and date the Declaration at the end of this document in addition to providing consent as appropriate.
Yours faithfully
Mrs N J EdmondsonDr P K Hazlewood
PrincipalChief Executive Officer
Please note that the information given on this form will be entered into our SIMS(Schools Information Management System) database. The ACADEMY is registered under the Data Protection Act. PLEASE COMPLETE THIS FORM IN BLOCK CAPITALS.
PROPOSED DATE OF ADMISSION: - / /
BASIC DETAILS of student:Please note the LEGAL SURNAME will be used on all examination certificates
LEGAL FORENAME
MIDDLE NAMES
LEGAL SURNAME
PREFERRED SURNAME
PREFERRED FORENAME
DATE OF BIRTH
GENDER
ADDRESS OF STUDENT & PARENT with whom the student lives
HOUSE NAME
HOUSE NO
STREET
district
TOWN/CITY
COUNTY
POST CODE
home telephone no
SIBLINGS
Please list below any siblings attending/ ever attended St John’s
name / COLLEGE & REG GRP
name / COLLEGE & REG GRP
name / COLLEGE & REG GRP
name / COLLEGE & REG GRP
CONTACT 1 - Please enter the contact details for Parent 1 with whom the student lives.
Indicate whether the email address is a home or work address.
TITLE & NAME / RELATIONSHIP
mobile telephone no
work telephone no
Email – primary(essential) / Home / Work
occupation / EMPLOYER
CONTACT 2 - Please enter the contact details for Parent 2/Responsible Adult with whom the student lives if
applicable. Indicate whether the email address is a home or work address.
TITLE & NAME / RELATIONSHIP
mobile telephone no
work telephone no
Email – primary (essential) / Home / Work
occupation / EMPLOYER
EMERGENCY CONTACT
CONTACT 3 - In the event of a real emergency the Academy would make every effort to contact the child’s parents on the numbers provided. Only if these attempts fail would we get in touch with the emergency contact who must be local enough to be able to help in such an eventuality. Please therefore do not repeat the information already supplied when completing this section.
TITLE & NAME / RELATIONSHIP
home telephone no
mobile telephone no
work telephone no
LEGAL GUARDIAN/ABSENT PARENT
Does any other person have parental responsibility for, but does not live with the student? If this is the case please enter the name and address of that person/persons here (note you are not legally obliged to give this information but the Academy is required to ask).
TITLE & NAME / RELATIONSHIP
House No/Name
STREET
district
TOWN/CITY
COUNTY & POST CODE
home telephone no
mobile telephone no
MEDICAL INFORMATION existing care plan: YES/NO (please circle)
surgery
telephone no
Please indicate any medical conditions, including medication, of which you feel we should be aware. Please state dose and time/s administered. In the case of allergies please state the severity and nature of the allergy.
1 - medical condition
1 – details/medication (if any)
2 - medical condition
2 – details/medication (if any)
3 - medical condition
3 – details/medication (if any)
ETHNICITY
The information below is a statutory requirement for the DfE please ‘‘ in appropriate box. (Only 1 tick per section).
ANY OTHER BLACK BACKGROUND / JAPANESE / WHITE
ANY OTHER MIXED BACKGROUND / MOROCCAN / WHITE BRITISH
BANGLADESHI / NEPALI / WHITE IRISH
BLACK AFRICAN / OTHER ASIAN / WHITE AND ASIAN
BLACK CARIBBEAN / OTHER ETHNIC GROUP / WHITE AND BLACK AFRICAN
CHINESE / PAKISTANI / WHITE AND BLACK CARIBBEAN
FILIPINO / THAI / WHITE EASTERN EUROPEAN
GYPSY ROMA / TRAVELLER OF IRISH HERITAGE / WHITE WESTERN EUROPEAN
INDIAN / TURKISH/TURKISH CYPRIOT / REFUSED
HOME LANGUAGE / FIRST LANGUAGE
“Home Language” is the language which they are exposed to at home. / “First Language” is the language to which a pupil was first exposed in their early childhood.
ARABIC / ARABIC
BENGALI / BENGALI
CHINESE(Cantonese/Mandarin/Hakka or Other) / CHINESE(Cantonese/Mandarin/Hakka or Other)
ENGLISH / ENGLISH
FINNISH / FINNISH
FRENCH / FRENCH
GERMAN / GERMAN
GUJERATI / GUJERATI
HINDI / HINDI
ITALIAN / ITALIAN
JAPANESE / JAPANESE
POLISH / POLISH
PORTUGUESE / PORTUGUESE
PUNJABI / PUNJABI
RUSSIAN / RUSSIAN
SPANISH / SPANISH
TAGALOG (Filipino) / TAGALOG (Filipino)
OTHER – Please state / OTHER – Please state
RELIGION
AGNOSTIC / HINDU / OTHER RELIGION
ANGLICAN / JEHOVAH’S WITNESS / ROMAN CATHOLIC SIKH
BAPTIST / JEWISH / SIKH
BUDDHIST / METHODIST / UNITED REFORM CHURCH
CHRISTIAN / MUSLIM / REFUSED
CHURCH OF ENGLAND / NO RELIGION
NATIONALITY
BRITISH / IRISH / SCOTTISH
ENGLISH / WELSH / OTHER
ENGLISH AS AN ADDITIONAL LANGUAGE
Please circle as appropriate YES / NO
ADDITIONAL INFORMATION Please circle only one as appropriate
MEAL TYPE / FREE SCHOOL MEALS / HOME / SCHOOL MEALS / PACKED LUNCH
MODE OF TRAVEL / BUS(type unknown) / CAR SHARE / CAR or VAN / CYCLE
DEDICATED SCHOOL BUS / WALK / PUBLIC BUS SERVICE / TAXI / OTHER
SERVICE CHILDREN IN EDUCATION – a student is deemed to come from a service family if at least one parent (living with the student) is currently serving in the Armed Forces (i.e. Royal Navy, Army or Royal Air Force)
Please circle as appropriate YES / NO / REFUSED
DISABILITIES
We are committed to making sure that St John’s is a happy and successful experience for all of our students. Where a student has a particular difficulty or need we will do our best to put measures in place to overcome this.
1 - Please indicate whether your child has any health problems or disabilities which mean that they have substantial difficulties with any of the areas of his/her life shown below? Please tick all that apply.
By long-standing we mean anything that has troubled them over a period of at least 12 months or that is likely to affect them for at least 12 months. Please exclude difficulties that you would expect for a child of that age.
If none apply please go to SCHOOL HISTORY section on page 5.
MOBILITY – MOVING AROUND INDOORS OR OUTDOORS
HAND MOVEMENTS – TOUCHING OR HOLDING
PERSONAL CARE – GOING TO THE TOILET, DRESSING
EATING AND DRINKING WITHOUT HELP
INCONTINENCE – WETTING OR DIRTYING
TAKING MEDICATION (please provide details in MEDICAL INFORMATION section above)
COMMUNICATION - SPEAKING WITH OTHERS, OR UNDERSTANDING THEM
LEARNING – NUMBERS, LETTERS, WORDS
HEARING IMPAIRMENT
VISION IMPAIRMENT
BEHAVIOUR – VERY ACTIVE, HAS A SHORT ATTENTION SPAN, BEHAVES UNACCEPTABLY
HAS FITS OR SEIZURES
DIAGNOSED WITH AUTISM OR ASPERGER’S SYNDROME
HAS A LIFE-LIMITING CONDITION OR REQUIRES PALLIATIVE CARE
CAN BE DEPRESSED, OR ANXIOUS, OR HAS AN EATING DISORDER
OTHER (PLEASE DESCRIBE OTHER AREAS OF GREAT DIFFICULTY) please include here whether your child needs special Access Arrangements (including for example extra time, a scribe or reader in exams or internal assessments).
Please circle to indicate whether you can provide proof of Access Arrangements. YES/NO
SPECIAL EDUCATIONAL NEEDS:
Please Circle if your child is considered to: Require additional SEN support
Please Indicate if your child has a Statement/ EHC Plan:YES / NO
DISABILITIES - continued
2 - Does your child take any medication, use any physical aids or require any special diet or supplements? / YES / NO
3 - If your child did not take this medication, use this physical aid or have a special diet or supplements, would he/she have substantial difficulties with any of the areas of life listed previously? / YES / NO
4 - Has your child seen a professional, such as a paediatrician or a psychologist or a speech and language therapist because of the difficulty? / YES / NO
If YES, please provide further details:
Adopted from care and the pupil premium
We need to record students who were looked after immediately before adoption on or after 30 December 2005*, being placed on a special guardianship order (SGO) or residence order (RO). The primary reason for collecting this data item is because from April 2014 eligible pupils adopted from care or who left care under an SGO or RO will attract pupil premium funding of £1900.
Parents should provide supporting evidence, for example, a photocopy of the adoption order. Parents may conceal sensitive information (e.g. the name of the birth parents).
*30 December 2005 was the date when the Adoption and Children Act 2002, which reformed adoption and introduced Special Guardianship Orders, came into force.
please ‘‘ in appropriate box. (Only 1 tick).
Ceased to be looked after through Adoption on or after 30 December 2005
Ceased to be looked after through a Special Guardianship Order (SGO) on or after 30 December 2005
Ceased to be looked after through a Residence Order (RO)
Ceased to be looked after through a Child Arrangement Order (CAO)
SCHOOL HISTORY
PREVIOUS SCHOOL
DATE OF ADMISSION / DATE OF LEAVING
REASON FOR LEAVING
STREET
TOWN/CITY
COUNTY & POST CODE
Please sign and date the Declaration and in addition provide your consent in the three other sections below.
DECLARATION:
I certify that the information provided in this form is accurate and correct. I undertake to inform St John’s of any changes in the personal and medical circumstances of my child (e.g. change of address, emergency telephone contact number, etc) and any change in any aspect of parental responsibility.
Signed: ______(Parent) Date: ______
ELECTRONIC COMMUNICATION:
I DO NOT WISH to receive generic correspondence, notices, newsletters & student reports electronically via SIMs InTouch from St John’s.
Signed: ______(Parent)
PHOTOGRAPHS:
The Academy is required by law, and in accordance with the Data Protection Act, to seek parental permission prior to creating images of children who attend St John’s. This usually applies to photographs. St John’s holds photographic records in order to be able to identify a child and on occasion photographs are taken at sports days, special events and sometimes for Academy publications. If you specifically object to any of the above, please notify me in writing. St John’s is only responsible for photographs taken by the Academy or an authorised agent of the Academy and cannot be responsible for photographs taken by other third parties, such as parents. The media are not subject to the DP Act or these guidelines and the Academy cannot prohibit the media from taking pictures or using the names of any child.
I/WE DO GIVE CONSENT for photographs to be taken and displayed of my/our son/daughter at St John’s Marlborough.
Signed: ______(Parent)
OUT OF ACADEMY/AFTER ACADEMY ACTIVITIES:
As part of normal Academy activities there are occasions throughout the year when students are off site in the environs of Marlborough: to visit churches; carry out surveys in the High Street; visit the Youth Centre as part of the Personal and Social Education programme; or to participate in sporting activities with other local schools.
On these occasions, we will assume we have your permission to include your child/children in any Out of Academy Activity during the timetabled day. If you do not give your consent, please notify me in writing and on such occasions the student will be asked to remain in the confines of the Academy and undertake supervised studies.
I/WE DO GIVE CONSENT for the above named student(s) to be included in any local ‘Out of Academy Activities’ or ‘After Academy Activities’ throughout the current academic year.
Signed: ______(Parent)
EMERGENCY ACADEMY CLOSURE:
Should an emergency arise during the academy day, the Principal has the responsibility to decide what action to take and one outcome could be closure of the Academy. Guidelines are:
- Students in Years 7 & 8 would be sent home to a responsible adult;
- Students in Years 9-13 could make their own way home and be deemed responsible enough to be home alone;
- Arrangements would be made to take home all students who travel in organised transport with the normal providers.
I would like you to make contingency arrangements for your child, and with your child, should the decision be made to close the Academy during the day; particularly if you have a child/children in Year 7 and/or Year 8. The arrangements should be safe and familiar to your child and may be the family home or the home of a relative should both parents not be at home during the day. Please reinforce this arrangement with your child particularly over the winter months.
I confirm that I have made safe arrangements for my child/children, and have agreed these arrangements with them, should St John’s close during the academy day.
Signed: ______(Parent)
FAIR PROCESSING NOTICE
Excalibur Academies Trust processes personal data about its students and is a “data controller” in respect of this for the purposes of the Data Protection Act 1998. It processes this data to:
• support students’ teaching and learning;
• monitor and report on their progress;
• provide appropriate pastoral care, and
• assess how well the Academy as a whole is doing.
This data includes contact details, national curriculum assessment results, attendance information, characteristics such as ethnic group, special educational needs and any relevant medical information.
This data may only be used or passed on for specific purposes allowed by law. From time to time the Academy is required to pass on some of this data to local authorities, the Department for Education (DfE), and to agencies that are prescribed by law, such as the Qualifications and Curriculum Agency (QCA), Ofsted, the Health and Social Care Information Centre (HSCIC) previously the Department of Health (DH) and Primary Care Trusts (PCT). These are data controllers in respect of the data they receive, and are subject to the same legal constraints in how they deal with the data.
The Trust Board of an academy in England is also required by law to supply basic information. This only includes the name and address of the child, contact details for their parents or carers (with parental responsibility) and the contact details of the academy.
Students, as data subjects, have certain rights under the Data Protection Act, including a general right to be given access to personal data held about them by any data controller. The presumption is that by the age of 12 a child has sufficient maturity to understand their rights and to make an access request themselves if they wish. A parent would normally be expected to make a request on a child’s behalf if the child is younger.
If you wish to access your personal data, or that of your child, then please contact the relevant organisation in writing. Details of these organisations can be found below.
Excalibur Academies Trust, Data Protection Officer, Granham Hill, Marlborough, Wilts SN8 4AX Tel: 01672 516156.
Local Authority (LA) Protection Officer, Wiltshire LEA, County Hall, Trowbridge, Wilts BA14 8JB
Qualifications and Curriculum Authority (QCA)
Ofsted Management Team, Freshford House, Redcliffe Way, Bristol BS1 6NL
Health and Social Care Information Centre Trevelyan Square, Boar Lane, Leeds, LS1 6AE
Department of Education (DfE) Public Communications Unit, DfE, Sanctuary Buildings, Great Smith Street, London SW1P 3BT