Akiva School Pupil Information Form
This registration form is for new pupils starting at Akiva School.  Any information entered into this form will be treated confidentially.


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Information about your CHILD
Last Name *
First Name *
Second Name/s
Known / Preferred Name *
Date of Birth *
Gender *
Name/s of any siblings at Akiva School *
What class/es are your child's sibling/s currently in?
House name or number *
Road/Street name *
Town *
City/County *
Postcode *
First Parent/Carer's Contact Details
Title *
First Name *
Last Name *
Address *
Required
House name or number
Road
City/County/Town
Postcode
Home telephone number
Mobile telephone number *
Work number
Email address *
Relationship to child *
Parental Responsibility *
Please indicate any disability issues that the school may need to take into account to help you.
Second Parent/Carer's Contact Information
This will be the second person we contact in case of emergency and will have authority to take the child home from school at any time
Title *
First Name *
Last Name *
Address *
Required
House Name or Number
Road
City/County/Town
Postcode
Home Telephone number
Mobile Telephone Number *
Work Telephone Number
Email address *
Relationship to Child *
Parental Responsibility *
Required
Additional Emergency Contact Information (or anyone who may have temporary/intermittent care of the pupil)
Title *
First Name *
Last Name *
Relationship to Child *
Parental Responsibility *
Home Telephone Number
Mobile Telephone Number *
Work Telephone Number
Email Address *
Please indicate (only if relevant) any disability issues that the school may need to take into account to help you.
Text Messaging service
The school uses a text messaging service and will send text messages with information pertaining to pupils such as emergency school closures, change of pick up times, stop and drop reminders etc.  Due to cost implications, our current provision is only for one number per family unless parents live apart and both would need the information.  Please write in the name and number of the contact we should add to the list below.
Full Name of Contact and Relationship to Child for texting service *
Mobile number for texting service *
Name of Child's Nursery/Preschool/School *
Address & Telephone number of Child's Nursery/Preschool/School *
Please give the name/s of up to TWO children you would like your child to be placed with.  We will try our best to ensure your child is placed in a class with at least ONE of these named children. *
Child's Health Information
Does your child have an identified special educational need or disability? *
If "Yes" to above, please give details
Does your child have an Educational Healthcare Plan (EHCP)? *
Has your child been seen by the Nursery's Area Special Educational Needs Co-ordinator (SENco)? *
If "Yes" to the above, please give details
Are there any external professionals involved with your child? e.g. Speech and Language Therapist, Occupational Therapist etc. *
If "Yes" to the above question, please give details
Medical and Dietary Information
Please give information on any significant medical issues or allergies that we should be aware of. You will be required to complete a full medical form at the beginning of term.

Doctor's Name *
Surgery Name: *
Surgery Address: *
Surgery Telephone number: *
Permission to call Doctor in an Emergency *
Does your child have any of the following conditions *
Required
Please give information on any medical conditions relating to your child
Does your child have any dietary requirements *
Required
Other dietary requirements including food allergy:
Free School Meal Entitlements *
Required
Transport *
What is your child's Ethnic origin? *
If "other Ethnic group" please indicate (or type N/A) *
Language Spoken at home *
Was English your child's first language? *
Religion *
Sharing information and images
In this section please let us know if you are happy for us to share information with other families and if you are happy for us to use images of your child in school
I agree to Akiva Primary School sharing my child's name and birthday with other parents in the class *
I agree to Akiva Primary School sharing parent/carer names and email addresses with the Parent Teacher Association (for class communications and PTA events) *
Please confirm whether you give permission for us to take, store and use photos of your child *
Yes
No
Internal use e.g. class/school displays & presentations
Our website
External media e.g. newspapers
Please confirm whether you give permission for us to take, store and use video & audio footage of your child *
Yes
No
Internal use e.g. class/school displays & presentations
Our website
External media e.g. newspapers
Walking Trips in the Local Area
From time to time the children make short local trips e.g. to the post box, local shop etc. For longer trips by coach or public transport we will always seek specific permission but we would appreciate your general consent for local walks.
As a Parent/Guardian/Carer I give permission for the named child on this form to take part in short walking trips in the local area. *
Agreement
Thank you for taking time to complete this form.  By submitting this form you agree to Akiva Primary storing and using this data about your child and your family for all reasons related to their education and well being at Akiva School.
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