Student Name:
Enrolment Form 2015
1.
Personal Details of Student:
First Name:
Surname:
Preferred Name:
Current home address:
If there is someone whom we should, by law, send
reports and information to please complete below
Name:
Address:
Postcode:
Postcode:
Contact Telephone Number:
Parental Responsibility: Yes/ No
Relationship to child:
Student Email Address:
Parent Email Address:
2.
Student Mobile:
Parent Mobile:
Male / Female
Date of Birth:
Current School:
Current School Year:
Emergency Contact Details
First Parent/ Guardian Details
(First person to contact in an emergency)
Second Parent/ Guardian Details
(Second person to contact in an emergency)
Name:
Name:
Relationship to Child:
Relationship to Child:
Parental Responsibility:
Address:
Yes/ No
Postcode:
Mobile Telephone Number:
Parental Responsibility:
Address:
Yes/ No
Postcode:
Mobile Telephone Number:
First emergency number must be a current mobile number
Home Telephone Number:
Work Telephone Number:
Home Telephone Number:
Work Telephone Number:
□ Please tick if you are happy for us to contact you by text message with information about your child
Student Name:
3. Residency
Have you lived in the UK for life?
If you answered NO to the above, how long have you lived in the UK?
If you lived outside the UK/ EU in the last three years, please provide details of the country(ies)
Do you depend on a visa or other permission to reside in the UK?
If yes, what type of visa do you have?
Expiry Date:
4. Medical Details
Doctor:
Doctor’s Address:
Postcode:
Doctor’s Telephone Number:
Does your child have any of the following conditions? (please tick)
Asthma
Cerebral Palsy
Diabetes
Eczema
Epilepsy
Hay Fever
Hydrocephalus
Hypotension
IBS
Kidney Problems
Any other conditions we should be aware of?
Does your child have any allergies?
Severe reactions to insect bites/stings
If yes – please provide details:
Mastoid
Migraines
Multiple Sclerosis
Rheumatism
Spinal Scoliosis
Tinnitus
Allergic reactions to medicines
If yes – please provide details:
Any other allergies?
Is your child up to date with their immunisations?
When did you child last have a Tetanus immunisation?
If your child needs to take regular medication, please ensure that a letter and any instructions which are
required are left with our Director of Inclusion & Student Support Services – Mrs Karen Whiffen.
□ If you would like the Student Support Services Team to contact you to discuss your needs in relation
medication, please tick.
Yes/ No
Yes/ No
Student Name:
Has your child seen any of these people? (please tick)
Educational Psychologist
Education Welfare Officer
Social Worker
Please outline the reason why and what intervention
has taken place.
5. Support Needs (including disabilities or learning difficulties)
Do you feel your child has a disability/ learning difficulty?
If YES, please tick the appropriate box(es) below:
Visual impairment i.e. difficulty seeing
Profound or complex disability
Hearing impairment i.e. difficulty hearing
Autism spectrum disorder / Asperger’s Syndrome
Disability affecting mobility i.e. difficulty
moving
Moderate learning difficulties
Other physical disability
Severe learning difficulties
Other medical condition eg. epilepsy, asthma,
diabetes
Emotional/behavioural difficulties
Dyslexia
Mental ill health ie. depression, anxiety,
schizophrenia
Other specific learning difficulties
Temporary disability ie. broken leg or arm
Multiple learning difficulties
Dyscalculia
Is your child currently supported for SEND? (SEN Support Level (K))
Has an application been made or given for statutory assessment or EHC Plan? (please delete) Made/ Given/
No
If YES, Which Local Authority gave the Statement or EHC Plan?
What was the statement/EHC Plan given for?
And when?
What interventions were put in place at your previous educational establishment?
Do you have any pre-existing access arrangements or reasonable adjustments for examinations?
If Yes, please provide details:
□ If you would like the Student Support Services Team to contact you to discuss your needs, please tick.
Yes/ No
Student Name:
6. Armed Forces
Are you currently serving in the Armed Forces? (either parent)
7. Free School Meals
Yes/ No
Do you receive (or are you entitled to receive) Free School Meals? Yes/ No
If you are entering Year 12, were you entitled to Free School Meals in Year 11? Yes/ No
Have you been in receipt of Free School Meals for the past 6 years or more? Yes/ No
What will your child do at lunch time? (please tick)
Free School Meal
Paid School Meal
Packed Lunch
8. Dietary Requirements
Does your child have any dietary requirements? (please tick)
Artificial Colouring Allergy
No nuts of any type/quantity
Seafood Allergy
Gluten Free
No Pork
Vegetarian
Halal
Kosher Foods Only
No Dairy Produce
Other
Please specify
9. Ethnicity
Please tick the option that best describes your ethnic group or background. Providing this information will
enable the UTC to monitor the provision for individuals and groups of pupils, ensuring equality of opportunity.
Afghan
Greek
Portuguese
African Asian
Gypsy - Roma
Sri Lankan Other
Albanian
Indian
Sri Lankan Tamil
Arab
Iranian
Turkish
Asian - Other
Iraqi
White – English
Bangladeshi
Italian
White – Black African
Black – Congolese
Japanese
White – Black Caribbean
Black – Nigerian
Kosovan
White – Chinese
Black – Somali
Kurdish
White Eastern European
Black – Sudanese
Lebanese
White European
Black – Other
Libyan
White Other
Black – Caribbean
Other Black
Yemeni
Black – European
Other Black African
Chinese - Other
Other Chinese
Croatian
Other Ethnic Group
Egyptian
Other Mixed Background
Filipino
Other Pakistani
Language(s) spoken in the home?
Language(s) understood in the home?
Do you receive support for English as an Additional Language? Yes/ No
What does this support currently entail?
Student Name:
10. Statement of accuracy and acceptance
• I declare that, to the best of my knowledge, the information I have provided is correct and that should my
circumstances change, I will notify the UTC immediately
• I undertake to attend regularly and punctually all courses for which I enrol and conform to the regulations
of the UTC
• I agree to abide by the requirements of various Acts covering health and safety and to follow instructions
issued by UTC staff
• I have read, or been given the opportunity to obtain and read, the course outlines.
Parent Signature:
Student Signature:
Date:
How We Use Your Personal Information
The personal information you provide is passed to the
Department for Education, including the Education Funding
Agency to meet legal duties under the Apprenticeships,
Skills, Children and Learning Act 2009, and for the Agency’s
Learning Records Service (LRS) to create and maintain a
unique learner number (ULN). The information you provide
may be shared with other partner organisations for
purposes relating to education or training.