Barns Green Primary School
Pupil Information Sheet

The information you provide will be treated in confidence but may be used internally for other registered purposes (Data Protection Act)

Office Use:

Start Date: …………………………..
Class………………………………...
UPN: ……………………………….
Birth certificate seen: YES/NO

Child’s Legal Surname ………………… 		Known as ……………………………. 
(As stated on birth certificate)				(If different from legal name, official documentation is req’d)

Child’s First & Middle Name ……………………………………………………. (Boy/Girl)

Date of Birth……………………………..….	Child’s Position in Family 1st 2nd  3rd 4th 5th 6th 
Country of Birth………………………………							

Home Address…………………………………………………………………………………………………………………………….
 (Please provide proof of residency i.e. utility bill/tenancy agreement)

Post Code ………………………………………….	Home Telephone Number …………………………………………			
Ethnicity ………………………………………….	1st Language spoken at home ………………………………….
(See attached sheet for further information)

Mother’s Full Name……………………	Work Telephone Number ……………………………........
(Mrs/Miss/Ms)
Resides with child  YES / NO		Mobile Number ………………………………………………
						
						Email address………………………………………………..

Father’s Full Name……………………	Work Telephone Number ……………………………........

Resides with child  YES / NO		Mobile Number ………………………………………………
						
						Email address………………………………………………..

Legal Guardian’s Full Name…………	Work Telephone Number ……………………………........

…………………………………….…….	Mobile Number ………………………………………………
(Legal documentation must be produced)
						Email address………………………………………………..

In case of emergency and in case parents cannot be reached please give two emergency contacts. This must be someone who is willing and able to collect your child during and after school hours.

Name ………………………....................		Name ………………………....................
(Mr/Mrs/Miss/Ms)					(Mr/Mrs/Miss/Ms)
Telephone Number ……………………….……		Telephone Number ……………………….……
Relationship to child ……………….………….		Relationship to child ……………….………….
Name of Doctor…………………………………..	Telephone Number ………………………………………..

Address of Surgery …………………………………………………………………………………………………………………...

Medical Conditions or Allergies

If your child has any specific medical conditions or allergies, please complete separate sheet attached.

Signature of Parent/Carer/Legal Guardian………………………………………………………………………..

Date …………………………………

Collection of Child From School

I will / I will not normally collect my child from school. I give permission for ………………………………

................................................ to collect my child . Relationship to child ………………………………

Background

Lives with mother and father 		(   )

Lives with mother				(   )

Lives with father				(   )

Lives with mother and stepfather	(   )

Lives with father and stepmother	(   )

Lives with legal guardian			(   )

Other (Please detail) …………………………………………………………………………………………………………………………

Any further information (eg. Any family disability or family circumstances that may be relevant to the child)

……………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………….

Previous History

Nursery/Playgroup/School Attended …………………………………………………………………………………………………

Address & Telephone Number ……………………………………………………………………………………………………………

Starting Date:

Month ……………..	Year ……………	Number of terms attended …………………

General

Mode of Transport	Walk (   )	Car (   )	Bicycle (   )	Other ……………………………………

Meal Arrangements
Free School Meal  (   )	Paid School Meal   (   )	 Sandwiches (   )
Ethnicity

Bangladeshi
Black – African
Black – Caribbean
Chinese 
Gypsy/Roma
Indian
Jewish
Pakistani
Traveller of Irish Heritage
White – British
White – Irish
White & Asian
White & Black African
White & Black Caribbean 
Any other Asian background
Any other Black background
Any other Ethnic background
Any other Mixed background

Home Language

English
Akan/Twi-Fante
Albanian/Shqip
Amharic
Arabic
Bengali
Bengali (Sylheti)
British Sign Language
Caribbean Creole English
Caribbean Creole French
Chinese
Cornish
Danish
Dutch/Flemish
Finnish
French
Gaelic (Scotland)
Gaelic (Ireland)
German
Greek
Gujarati
Hebrew
Hindi
Igbo
Italian
Japanese
Korean
Kurdish
Lingala
Luganda
Manx Gaelic
Norwegian
Panjabi
Pashto/Oakhto
Persian/Farsi
Polish
Portuguese
Romany/English Romanes
Russian
Serbian/Croatian/Bosnian
Sinhala
Somali
Spanish
Swahili/Kiswahili
Swedish
Tagalog/Filipino
Tamil
Turkish
Urdu
Vietnamese
Welsh/Cymraeg
Yoruba

Please tick the above for your child’s ethnicity and home language

Child’s Religion _________________________________

Signed Parent/Carer _____________________________
Barns Green Primary School
Pupil Health Information Form

This form is used to help the school understand the medical needs of your child whilst in school and is used to plan the provision of their care. This information will be kept securely with your child’s other records. If further information is required, we will contact you.

Please do not hesitate to contact the school if there are any issues you wish to discuss, or if you do not feel comfortable completing this form.

Child’s Name

	Date of Birth	
Gender

	Year Group	

Has your child been diagnosed with, or are you concerned about, any of the following:

Condition	Yes	No 	Medication	
Asthma

				
Allergies

				
Epilepsy

				
Diabetes

				

Is your child taking regular medication for any condition other than those listed on the previous page

Condition	Medication / Emergency Requirements	
		
Please use the space below to tell us about any other concerns you have regarding your child’s health:

Parent/guardian consent to administer short-term non-prescribed ‘ad-hoc’ medicines

The school will not administer medication unless this form is completed and signed. This information will be kept securely with your child’s other records. If further information is needed we will contact you. Please do not hesitate to contact the school if there are any issues you wish to discuss.

The Medicines Policy permits the school to administer the following non-prescription medication if your child develops the relevant symptoms during the school day. Pupils will be given a standard dose suitable to their age and weight. You will be informed when the school has administered medication by email/information slip home. The school holds a small stock of the following medicines. 

                
              Paracetamol                                       Administered with no adverse effect

               Anti-histamine                                        Administered with no adverse effect

Tick the non-prescription medications above that you give your consent for the school to administer during the school day and confirm that you have administered these medications in the past without adverse effect. Please keep the school informed of any changes to this consent. 

Signature Parent/Guardian…………………………………….

Print Name…………………………………..

Date……………………………………………..