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____________________________________________________
