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Elective Home Education - Checklist
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* Indicates required question
Email
*
Your email
Name & role of referrer completing this form
*
Your answer
School Name
If this referral is from a school located outside of RBWM, please state below
*
Your answer
Please note, the parent/carer de-registration letter must be sent to harmit.thiara@achievingforchildren.org.uk in order for this referral to be accepted
*
De-registration letter has been sent to
Harmit.Thiara@achievingforchildren.org.uk
Required
Pupil UPN (Unique Pupil Number)
*
Your answer
Pupil Name
*
Your answer
Pupil DOB
*
MM
/
DD
/
YYYY
Pupil Year Group
Your answer
Pupil Address
*
Your answer
Pupil Ethnicity
*
Your answer
Pupil Gender
*
Your answer
Parent/Carer reasons for home education
*
Alternative education sought
Anxiety & depression
Best option for pupil
Bullying
COVID19
Cultural differences
Curriculum
Finance reasons
Health & medical
SEN
New to area
Moving out of area
None transfer to next school phase
Emotional related school avoidance
Awaiting school place
None stated
Please expand on your answer above and provide further details of the reason for EHE
*
Your answer
Date/intended date to remove from roll (include 20 day grace period if agreed by school & parent)
*
MM
/
DD
/
YYYY
Parent/Carer details
Parent/Carer Names
*
Your answer
Parent/Carer Telephone Numbers
Please specify which number belongs to the named parent/carer
*
Your answer
Parent/Carers Email Addresses
Please specify which email address belongs to the named parent/carer
*
Your answer
Do both parents/carers you have named above have parental responsibility?
Please specify below
Your answer
Safeguarding & Special Educational Needs information
Have there been any safeguarding concerns whilst the pupil has attended your setting or previous settings?
*
Yes
No
If answered yes to safeguarding concerns, please include all dates & details of the concerns below (if you answered no, please type N/A)
*
Your answer
Is the pupil currently or has the pupil historically been subject to an early help or social care plan?
*
Early Help plan
Child in need plan
Child protection plan
Child in care plan
Historically subject to an early help plan
Historically subject to a child in need plan
Historically subject to a child protection plan
Previously looked after child
Pupil has never been subject to an early help or social care plan
Is the child on your SEN register?
*
Yes
No
If you have answered yes, please outline special educational needs below, including the pupil's primary need (if you have answered no, please put N/A)
*
Your answer
Does the child have an EHCP?
*
Yes
No
Under assessment
Responsibility check
Have all safeguarding concerns been disclosed within this form?
*
Yes
No
Do you have any concerns with parent/carer opting to Electively Home Educate their child?
*
Your answer
Has the school met with parents/carers to discuss Elective Home Education and the reasons behind the referral?
*
Yes
No
Please tick if the following members of staff have been made aware of the Elective Home Education notification from parents/carers
Please note that if there are current safeguarding concerns, the DSL must be informed before submitting this form
*
Head Teacher
Designated Safeguarding Lead
Head of Year
Form Tutor/Class Teacher
Required
A copy of your responses will be emailed to the address you provided.
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