Data Collection & Sharing Form

Child's Name*

First NameMiddle NameLast Name

Preferred Name (if different)

First NameLast Name

Date of Birth*

DayMonthYear

Gender*

MaleFemale

Is your child already attending Broom Barns Primary School?

YesNo

What is the NAME of the school they have been attending?

What is the ADDRESS of the school they have been attending?

Class*

National Health Service Number (NHS)*

10 Digits - from your litle red book or a GP/hospital letter

Address*

Street Address

TownCounty

Post Code

Home Language*

Ethnicity*

Religion*

Service Child in Education*

Are you/your partner in the armed forces?

GP Surgery*

Name / Surgery

Medicial Conditions

Hayfever etc.

If your child is prescribed emergency, life saving medication such as asthma inhalers or epi-pens please bring the medication in to school in the original container with the prescription label attached. Please ensure we always have up-to-date and indate medications (kept in school).

Does your child have asthma or require an epi-pen?*

YesNo

In the event of an emergency and your child's inhaler is not available we will use the school salbutamol inhaler.*

I agree with the statement above.

IMPORTANT - All dinners must be paid for up front to Dolce via 'The School Grid' website. If the dinner has not been paid for, we will not be able to give your child a school meal that day.

Dietary options*

e.g. None, vegetarian, vegan etc.

IMPORTANT
If your child has a food allergy please ensure you complete the allergy section on the 'School Grid' online form before your child has any school meals.

Is your child entitled to benefit-related free school meals?

Yes - IMPORTANT please speak to the school office for help arranging for these to continue.No

Please give details of all persons who have parental responsibility and anyone else you wish to be contacted in an emergency (A MINIMUM OF THREE PEOPLE ARE REQUIRED). Place them in the order that you wish for them to be contacted in an emergency. If you wish to add more than 6 people please see the office staff.

Name of Main Contact 1 (MUST BE A PARENT/CARER*

TitleFirst NameLast Name

Relationship to child*

Date of Birth for Parent/Carer*

DayMonthYear

Address if different from child

Street Address

Street Address Line 2

TownCounty

Post Code

Email address*

National Insurance no.*

Parents only

Mobile Number*

numbers only

Home Number

numbers only

Work Number

numbers only

Place of work & department

Name of Main Contact 2*

TitleFirst NameLast Name

Relationship to child*

Address if different from child

Street Address

Street Address Line 2

TownCounty

Post Code

Please choose one option below*

Emergency contact and can collect the childCan collect the child but is NOT an emergency contact

National Insurance no.*

Parents only

Email address*

Mobile Number*

numbers only

Home Number

numbers only

Work Number

numbers only

Place of work & department

Name of Main Contact 3*

TitleFirst NameLast Name

Relationship to child*

Address if different from child

Street Address

Street Address Line 2

TownCounty

Post Code

Mobile Number*

numbers only

Home Number

numbers only

Work Number

number only

Place of work & department

Email address

Please choose one option below*

Emergency contact and can collect the childCan collect the child but is NOT an emergency contact

Would you like to add another adult?*

YesNo

Name of Contact 4*

TitleFirst NameLast Name

Relationship to child*

Address if different from child

Street Address

Street Address Line 2

TownCounty

Post Code

Mobile Number*

numbers only

Home Number

numbers only

Work Number

number only

Place of work & department

Please choose one option below

Emergency contact and can collect the childCan collect the child but is NOT an emergency contact

Would you like to add another adult?*

YesNo

Name of Contact 5*

TitleFirst NameLast Name

Relationship to child*

Address if different from child

Street Address

Street Address Line 2

TownCounty

Post Code

Mobile Number*

numbers onlu

Home Number

numbers only

Work Number

numbers only

Place of work & department

Please choose one option below

Emergency contact and can collect the childCan collect the child but is NOT an emergency contact

Would you like to add another adult?*

YesNo

Name of Contact 6*

TitleFirst NameLast Name

Relationship to child*

Address if different from child

Street Address

Street Address Line 2

TownCounty

Post Code

Mobile Number*

numbers only

Home Number

numbers only

Work Number

numbers only

Place of work & department

Please choose one option below

Emergency contact and can collect the childCan collect the child but is NOT an emergency contact

DECLARATION
The information I have given on this form is complete and accurate. I understand that the information will be held securely and will be used only for local authority purposes.

Educational Data Sharing - Websites and programs the school needs to use for educational purposes.

I confirm I understand the reasons that the data I put on the data collection sheet is shared. I will indicate my permission for my child’s data to be shared with the following sites on the table below. I understand that I may withdraw my permission at any time by completing a new form.

Arbor –A parent-school portal . Contact information only for those with parental responsibility is shared with this provider. *