ST MARY'S CATHOLIC PRIMARY SCHOOL
New Pupil Response Pack ![]()
Please find below information from our Permissions Slip, which accompanies our New Pupil Information Booklet. This can be translated into different languages using the Google Translate button above.
Information Collection
Child’s Surname: _________________________________________
Legal Surname:(if different) ________________________________________
Forename: _________________________________________
Middle Name: _________________________________________
Preferred Name: _________________________________________
Gender: _________________ Date of Birth:_______________
Address: ____________________________________________
______________ Postcode______________________
Contact Details
Please give details of all persons who parental responsibility and to anyone else you wish to be contacted in an emergency. Place them in the order that you wish them to be contacted in an emergency.
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Name & Relationship |
Address |
Phone/Email |
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Email: Home No. Mobile No. Work No. |
Absent Parents
If not included in the contact details, please give information of any person/s below who have parental responsibility for your child and do not live with you. This information is required so that we can carry out our statutory duties and inform everyone with parental responsibility of his/her child’s progress at St Mary’s.
Name: __________________________________________________
Address: __________________________________________________
Postcode ______________________________________
Email: ____________________________________________
Contact Numbers: ____________________________________________
Other information:
Religion: __________________________________________________
Dietary Needs/Allergies: __________________________________________________
___________________________________________________
Medical Practice __________________________________________________
Contact No: ________________________________________
Medical Notes: __________________________________________________
__________________________________________________
SEN/ Additional Needs (please include previous or existing SEN needs):
__________________________________________________
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Please indicate whether your child has any long-standing illnesses, health problems or disabilities which mean that they have substantial difficulties with any of the areas of his/her life shown below? Please select all that apply. By long-standing we mean anything that has troubled them over a period of at least 12 months or that is likely to affect them over at least 12 months. Please exclude difficulties that you would expect for a child of that age |
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Mobility – moving around indoors or outdoors |
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Hand movements – touching or holding |
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Personal care – going to the toilet, dressing |
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Eating and drinking without help |
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Incontinence – wetting or soiling |
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Taking medication |
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Communication - speaking with others, or understanding them |
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Learning – numbers, letters, words |
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Hearing |
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Vision |
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Behaviour – very active, has a short attention span, behaves unacceptably |
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Has fits or seizures |
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Diagnosed with autism or Asperger Syndrome |
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Has a life-limiting condition or requires palliative care |
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Can be depressed, or anxious, or has an eating disorder |
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Other (please describe other areas of great difficulty) |
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If your child did not take this medication, use this physical aid or have a special diet or supplements, would he/she have substantial difficulties with any of the areas of life listed above? |
Yes |
No |
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Has your child seen a professional, such as a paediatrician or a psychologist or a speech and language therapist because of the difficulty? |
Yes |
No |
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If YES, please provide further details: |
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If you have indicated above that your child has difficulties, do these difficulties affect his or her: |
Yes |
Sometimes |
No |
Don’t know |
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Classroom learning? |
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Interaction with his or her classmates / peers? |
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Joining in other school activities e.g. breaks, social and leisure activities? |
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Attendance at school |
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Day to day life outside of school |
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What sort of help, support or special equipment do you think your child needs so that they get on well at school? |
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We would be pleased to meet with you to talk about any of your child’s needs above. Please tick if you would like us to arrange this. |
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Ethinicity (Please study the list below and tick one box only)
White [ ] British [ ] Irish [ ] Traveller of Irish Heritage [ ] Gypsy/Roma [ ] Any other White background
Mixed [ ] White and Black Caribbean [ ] White and Black African [ ] White and Asian [ ] Any other mixed background
Asian/Asian British [ ] Indian [ ] Pakistani [ ] Bangladeshi [ ] Any other Asian background
Black or Black British [ ] Caribbean [ ] African [ ] Any other Black background
Other [ ] Chinese [ ] Any other ethnic background
[ ] I do not wish an ethnic background category to be recorded
Language(s) spoken by your child
At St Mary’s school we welcome families from many different places around the world. In order to support your child at school it would help us to know what languages are spoken by the family at home.
Language most commonly spoken at home
Language your child heard spoken and learnt first
English as an Additional Language status depends on which language was learnt first and is not a judgement on a child’s fluency in English.
[ ] I do not wish to wish to have my child’s language (s) recorded.
ParentMail
I give permission for my email address and mobile number to be registered with ParentMail.
Parent/Carer Details
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First Name |
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Mobile No. |
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Relationship to child |
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Primary contact : Yes/No *
- Primary Contact (Emails are sent to all contacts; however text messages will normally only go to the primary contact)
Permission Slip
Please tick in the box to give consent for the time your child is at St Mary’s:-
Educational Visits
[ ] I give permission for my child to take part in any educational trips or walks planned.
Food Tasting
[ ] I give permission for my child to take part in any food tasting activities planned.
[ ] I have listed below any dietary requirements/allergic reactions that should be taken into consideration and I will keep the school informed of any changes to this information.
Photography and Videoing
I give permission for:-
[ ] my child’s photograph to be taken during class activities, assemblies and trips for the purpose of display within the school to celebrate the work of the school.
[ ] my child to be included in the photography of school plays or sports day and outside activities such as camp or trips.
[ ] my child to be included in the videoing of school plays, sporting events and classroom or outside activities, such as camp or trips.
[ ] my child’s photograph to be taken and used in a newspaper report about an event at school. This can include items such as the annual Reception Class photo in the local newspaper.
[ ] my child’s photograph to be taken at school events, such as sports festivals, engineering competitions etc, for publicity of the event.
[ ] I understand that the photographs or videos may be taken by a member of staff or by a designated school adult acting on behalf of the school (this could be a parent). When working with the press no surname would be given.
School’s Website
I give permission for:-
[ ] my child’s photograph to be used in the context of a group/whole school activity.
[ ] my child’s photograph to be used if partaking in a PE/sporting/school activity off-site.
[ ] my child’s individual photograph to be used.
[ ] my child’s/children’s voice to be used on the website.
[ ] a video clip of my child/children involved in a group activity to be used.
ICT and E-Safety
[ ] I have read the E-Safety Policy, which is available on the school website and agree that, when considered appropriate by the school, my child will be taught safe use of the internet.
[ ] I have enclosed a completed form to see if my child is eligible for Free School Meals and Pupil Premium. I understand that this will be treated confidentially.
[ ] My child is already entitled to Free School Meals.
[ ] Having read the criteria, I am certain that my child will not be eligible for Free School Meals.
Donations and Gift Aid
[ ] I wish to make a £9 donation towards the maintenance and building work of the school, as part of being a voluntary aided school. Further information will follow.
[ ] I am a UK taxpayer and would like you to reclaim an additional 25% Gift Aid payment on my donation, at no extra cost to myself.
Name of taxpayer _____________________ Signature __________________
[ ] I do not wish to make a donation at this time.
School Milk
[ ] I give permission for my child to take part in the school milk scheme. I understand that, if I wish them to have milk after my child has reached his/her 5th birthday, it will be my responsibility to pay for the milk.
Pupils in Reception, year 1 and 2 only.
Fruit and Veg Scheme
[ ] I give permission for my child to take part in the Fruit and Vegetable Scheme. Pupils in Reception, year 1 and 2 only.
Please list below if your child has any allergies that we should be aware of.
_____________________________________________________________
Other
[ ] I am aware that the school’s Pupil Privacy Notice, along with other statutory polices, are available on the school website and it is my responsibility to regularly read this information in order to be aware of all procedures and statutory regulations.
Signed ________________________________ Date_______________________
Print name _________________________Relationship to child _________________