MEDMERRY PRIMARY SCHOOL

HIGH STREET, SELSEY, CHICHESTER, WEST SUSSEX PO20 0QJ   Telephone (01243) 602738

Please print

*Delete as appropriate

 

Child’s Legal Surname________________________________ Gender *Male/Female

First Names___________________________________ Date of Birth______________________

Known as_____________________________________

           

Child’s Current Address_____________________________________________________________

______________________________________________Postcode________________________

Home Telephone Number______________________________

 

New Address and date of move, if applicable________________________________________

___________________________________Postcode______________Date_______________

Please provide proof of new address – a signed tenancy agreement or exchange of contracts

Requested Date of Admission_____________________________________________________

 

Current School/Nursery/Playgroup________________________________________________

Address of Current School_________________________________________________________

Telephone number of Current School_____________________________

 

Parents should discuss a change of school with their child’s current school if the request is not related to a change of address.

Name and position of person_____________________________________________________

 

It is sometimes necessary to contact a parent/guardian should an emergency occur at school.  Please indicate below where each parent/guardian may be contacted during school hours.

 

*Mother/ Guardian’s Full Name *Mrs/Miss/Ms_______________________________________

Do you have legal responsibility?  *Yes/No

Daytime Tel. No._____________________        Mobile Phone No. ___________________________

Address if different to child_______________________________________________________

                                           ___            _____________________________________________________

 

*Father/Guardian’s Full Name ___________________________________________________

Do you have legal responsibility?  *Yes/No

Daytime Tel. No._____________________        Mobile Phone No.___________________________

Address if different to child________________________________________________________

                                         ____            _______________________________________________________

 

Name(s) of person(s) with legal parental responsibility if different from above:

*Mr/Mrs/Miss/Ms ________________________________________________________________

Are they in agreement with this application *Yes/No

Please note: The school cannot intervene where parents with joint responsibility disagree.

 

Please name up to two other local emergency contacts:

                                    1.                                                         2.

Name and Surname       ________________________            _______________________

Relationship to child     ________________________            _______________________

Tel. No             ________________________            _____________________________

Mobile No                    ________________________            _______________________

 

Details of any brothers or sisters

Name______________________________________ Date of Birth_____________________

Name______________________________________ Date of Birth_____________________

Name______________________________________ Date of Birth_____________________

Name______________________________________ Date of Birth_____________________

 

Which Medical Practice is your child registered with:

*Seal Medical Group

  *Selsey Medical Centre

  Other (please name)______________________________________________________

 

Does your child have any medical conditions of which the school should be aware? (Circle)

 

Epilepsy           Diabetes           Asthma Eczema Arthritis

 

Allergies (please give details)_______________________________________________________

_______________________________________________________________________________

 

Other (please give details) ________________________________________________________

_____________________________________________________________________________

 

 

Does your child wear spectacles?                     Never/Always/For close work only

 

Is your child left or right handed?                   Left-handed/Right-handed

 

What is your child’s First Language?______________________________________________

 

What do you consider to be your child’s ethnic origin? (Circle)

White U.K. Heritage         White European         White Other

Black African         Black Caribbean         Asian         Other

 

What do you anticipate will be your usual mode of travel to school? (Circle)

Bus                  Car/van Car share          Walk

 

Any other relevant information___________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

 

 

 

Parental Declaration

I have parental responsibility for this child. By signing this form I confirm that all the information given is legal and true. I understand that any offer of a place made as a result of this application may be withdrawn if I give false information or fail to notify the school of any changes.

 

Signed __________________________________          Print Name_________________________

 

Date ___________ Relationship to Child____________________________________________

 

Contact Telephone Number______________________________________________________

 

 

_____________________________________________________________________________

 

 

 

Looked After Children. Please complete this section if the child is in Public Care.

 

Responsible Social Workers Name__________________________________________________

 

Contact Telephone Number_____________________________________________________

 

Responsible Authority___________________________________________________________

 

Contact Numbers for Placement____________________________________________________

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Contact Details

Medmerry Primary School,
High Street,
Selsey,
West Sussex.
PO20 OQJ
Tel: 01243 602 738
Fax: 01243 605 274