Data Collection Form

Please complete the details below and return this form to your child’s class teacher as soon as possible.

1. Name: *

2. Date of Birth: *

3. Address (Please include house name and number): *

4. Postcode: *

Please give details of all persons who have parental responsibility and anyone else you wish to be contacted in an emergency. Place them in the order that you wish for them to be contacted.

Parent/Guardian - Priority 1

5. Relationship to Pupil, e.g parent: *

6. Surname: *

7. Forename: *

8. Title: *

Mrs

9. Address: *

10. Postcode: *

11. Home Telephone Number: *

12. Mobile Number: *

13. Work Name: *

14. Work Number: *

Parent/Guardian - Priority 2

15. Relationship to pupil, e.g parent: *

16. Surname: *

17. Forename: *

18. Title: *

Mrs

19. Address: *

20. Postcode: *

21. Home Telephone Number: *

22. Mobile Number: *

23. Work Name: *

24. Work Number: *

Parent/Guardian - Priority 3

25. Relationship to pupil, e.g parent: *

26. Surname: *

27. Forename: *

28. Title: *

Mrs

29. Address: *

30. Postcode: *

31. Home Telephone Number: *

32. Mobile Number: *

33. Work Name: *

34. Work Number: *

35. Medical Practice: *

36. Telephone Number: *

37. Address of Medical Practice: *

38. Medical Information: *

39. Special Dietary Needs: *

40. Ethnicity: *

41. Home Language: *

42. Religion: *

43. Travel Arrangements - Tick box of appropriate choice: *

Bus

Walk

Car

Data Protection Act 1998: The School is registered under the Data Protection Act for holding personal data. The school has a duty to protect this information and to keep it up to date. The School is required to share some of the data with the Education Authority and with the Department of Education.

44. Please indicate consent for your child to be included on our School Website, Facebook & Instagram Page. Our class teachers share learning acheivements and class celebrations on these platforms to include you in their learning journey. *

YES

45. I have been made aware of the relevant Child Protection/Safeguarding Policies and Complaints Procedure. I know where to access these on the school website and know that I can request a printed copy from the school office at any stage. *

Yes

46. Signed: *

47. Date: *

YYYY

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