ࡱ> a 8bjbjzz ŠP\P\Y0. pppppD4t^6\\rrr("("("!^#^#^#^#^#^#^$`ctG^p1#!@""1#1#G^pprrT\^(((1#^prpr!^(1#!^((Xl\r 6#RY* ^r^0^Yjd#dT\\dp]L("0X""(z""("("("G^G^%("("("^1#1#1#1#d("("("("("("("("(" > 6:  SIXTH FORM ADMISSION FORM All schools and academies are required by law to keep on record details of students admitted. We should therefore be grateful if you would complete this form in BLOCK CAPITALs and return to the Academy a.s.a.p. No student will be admitted to the Sixth Form without the submission of a completed Admission Form and Sixth Form Contract. Please sign pages 3,4 & 5. STUDENTS DETAILSLegal surname:Address:Legal forename:Preferred forename:Middle name/s:Date of birth:Gender: Male / Female It would be very helpful to have details of any siblings who are currently attending, or have attended this school.Siblings ForenameSiblings SurnameDate of BirthCurrent School CONTACT DETAILSParental responsibility may be shared between a number of people beyond the childs natural parents, for example those with a Parental Responsibility Order. Married parents have equal parental responsibility; on separation or divorce both parents continue to have responsibility. In such circumstances the Academy will forward copies of school reports, etc. to the separate parent if requested. Please attach a copy of any court orders relating to your child. PARENT/CARER 1Legal surname:Title: Mr / Mrs / Ms / Miss / OtherLegal forename:Address:Gender: Male / FemaleRelationship to student:Home telephone number:Mobile telephone number:Work telephone number:Email address:PARENT/CARER 2Legal surname:Title: Mr / Mrs / Ms / Miss / OtherLegal forename:Address: Gender: Male / FemaleRelationship to student:Home telephone number:Mobile telephone number:Work telephone number:Email address: If the childs current residence (whether living with parents or any other person) is not permanent, please state the reason, probable duration of the stay and give the name and address with whom the person normally resides: ReasonDates applicable:Forename:Surname:Address: Is the child resident with foster parents: Yes ( No ( Is the child resident with a family member who is not their legal guardian: Yes ( No ( It may be necessary to contact someone during the school day (generally in the case of sickness when a parent/carer cannot be contacted for whatever reason). Please list below details of anyone we can contact on such an occasion.ADDITIONAL CONTACT 1Legal surname:Title: Mr / Mrs / Ms / Miss / OtherLegal forename:Address:Relationship to student:Home telephone number:Mobile telephone number: MEDICAL INFORMATIONKnowledge about your childrens health is vital if we are to help them to achieve their educational potential. Please supply the following medical information about your child. This information will only be shared with relevant professionals within education and health who need to know in order to support your child in school. If you wish to discuss your childs health confidentially, please contact the First Aid Administrator.Dietary Needs( Artificial colour allergy( Gluten Free( Kosher food only( No dairy produce( No nuts of any type/quantity( No pork( Ramadan( Seafood allergy( Vegetarian( Halal( Other (please specify) ______________________ Medical PracticeSurgery Name:Surgery Telephone Number: Medical ConditionsDoes your child suffer from?( Asthma( Epilepsy( DiabetesBowel or bladder problemsEczemaAny other medical condition _____________________Do you consider your child to have a disability? Yes / No If Yes, please select all that apply from the list below. A child is considered to have a disability if their parent indicates substantial and/or long term difficulties with one or more of the areas listed below. Please exclude difficulties that you would expect for a child of their age. Mobility Hand Function Personal CareEating and drinkingMedicationIncontinenceCommunicationLearning HearingVisionBehaviourConsciousness e.g. seizuresASD/AspergersPalliative care needsOther Disability/Health problem __________________Does your child attend any medical clinics? - Yes / No (if Yes, please give details in the box below)If you have ticked any of the above boxes, please give further details below: If your child is on regular medication, does it need to be given during school hours? Yes / No If Yes please discuss with the First Aid Administrator. MEALSEligible for Free Meals TRAVEL ARRANGEMENTS please tick the main method of transport to and from schoolWalkCar/VanCar shareTrain/TubeCycleBusTaxi Service Children in Education Indicator - are one/both parents Service personnel, serving in regular military units of any of the HM Forces, or in the Armed Forces of another nation and stationed in England and exercising parental care and responsibility? ( Yes ( No ( I do not wish to answer this question ETHNICITY/CULTURAL INFORMATIONThe Department for Education has asked for the following information for all students. EthnicityWhite British Irish Traveller of Irish Heritage Gypsy/Roma Any other white background Asian or Asian British Indian Pakistani Bangladeshi Any other Asian background Mixed White & Black Caribbean White & Black African White & Asian Any other mixed background Black or Black British Caribbean African Any other Black background Other Chinese Any other ethnic group I do not wish an ethnic background category to be recorded  First Language (the language to which your child was first exposed in their early childhood and which they continue to use or be exposed to at home or in your community).ArabicBengaliChinese CantoneseChinese MandarinDutchEnglishFrenchGermanGreekGujaratiHindiItalianJapanesePanjabi (Gurmukhi)Panjabi (Mirpuri)PashtoPolishPortugueseShonaSpanishSwahiliTagalog/FilipinoTamilThaiTurkishUrduVietnameseOther (Please specify) ____________________________________I do not wish a first language to be recorded RELIGIONAnglicanBaptistBuddhistChristianChurch of EnglandHinduJehovahs WitnessJewishMethodistMormonMuslimPlymouth BrethrenQuakerRoman CatholicSikhUnited Reform ChurchNo ReligionI do not wish a religion to be recordedOther PREVIOUS SCHOOL HISTORYSchool Name and TownTelephone numberDate of ArrivalDate of LeavingReason for LeavingPARENTAL DECLARATION DATA PROTECTION STATEMENT: The purpose of this form is to collect data for further processing within Chiltern Hills Academy according to our Data Protection Policy and Privacy Notice. Information provided will be kept as a hard copy and also entered onto a computer and will form part of the Academy database. Your signature on this form implies your consent. DECLARATION OF PERSON WITH LEGAL RESPONSIBILITY: I confirm that I and my son/daughter will abide by the policies and procedures as set out in the Sixth Form Handbook and Sixth Form Contract. I declare the information provided on this form was correct, to the best of my knowledge, at the time of completion. I agree to notify the Academy of any change in my childs circumstances. Parent/Carers signature: ____________________________________________ Date: ___________________  CONSENT FOR ADMISSION AGREEMENTS AND POLICIES If you wish to withdraw your consent at any point please contact our Academy Data Protection Officer on dataprotection@chacademy.co.uk or by telephoning the Academy. Personal data is stored in accordance with our Privacy Notice for Parents/Carers and Students and Data Protection Policy. CONSENT FOR BIOMETRIC SYSTEM - PROTECTION OF FREEDOM ACT 2012 I give consent for the biometrics of my son/daughter to be used by Chiltern Hills Academy as part of the recognition system. Yes ( No ( If you wish to withdraw your consent at any point please contact our Academy Data Protection Officer on dataprotection@chacademy.co.uk or by telephoning the Academy. Parent/Carers signature: ____________________________________ Date: _________________ Name: _________________________________________________________________________  CONSENT FOR USE OF IMAGES OF STUDENTS CONSENT FOR USE OF IMAGES OF STUDENTS At Academy we take images (photographs, video and webcam recordings) of Academy performances, events, trips, activities and the general school day. These photographs/video recordings may be used in printed or electronic publications, printed or electronic media, our Academy website, social media (such as Chiltern Hills Academy Facebook and Twitter) or on internal displays. Chiltern Hills Academy believes that these images can provide a valuable record of the students learning. Learning takes places in a variety of different ways at the Academy and we like to celebrate and share this learning with others. Images of students and students successes can be a source of pleasure and pride, which we believe can enhance self-esteem for students, their families and the local community. Continues overleaf The Academy values using photographs or video recordings to be able to share and showcase the Academy environment as well as allow us to keep parents up to date with what goes on. To comply with the Data Protection Act and the General Data Protection Regulation 2018 we need your consent to take and use images of your child. Please tick the appropriate boxes below: I give consent for the Academy to take images of my child. Yes ( No ( I give consent for images of my child to be used on the Academy website. Yes ( No ( I give consent for the Academy to use images of my child in printed or electronic publications (such as the Academy prospectus, newsletter and letters to parents). Yes ( No ( I give consent for the Academy to use images of my child on internal displays. Yes ( No ( I give consent for the Academy to use images of my child in printed or electronic media. Yes ( No ( I give consent for the Academy to use images of my child in social media. Yes ( No ( If you wish to withdraw your consent at any point please contact our Academy Data Protection Officer on dataprotection@chacademy.co.uk or by telephoning the Academy. The Academy will take a photograph of all students, on entry by the Academy and subsequent year, by the Academys appointed professional photographer. This image will be used to update our Academy Database. The use of this image is required to carry out the task of educating and ensuring the welfare of our students. This image, along with full name, will be used to produce examination indentification cards. This image is collected and used in compliance with the General Data Protection Regulation 2018 under Article 6 (Lawfulness of Processing). Conditions of use: This form is valid until your child leaves Chiltern Hills Academy. The consent will automatically expire after this time. We will not reuse any photographs or recordings after your child leaves the Academy, however, historic images will remain on our Academy prospectus, printed and electronic publications, printed and electronic media, our Academy website and social media. We will not use the personal details, contact details or full names (which means first name and surname) of any child in an image on our Academy prospectus, printed and electronic publications, our Academy website and social media. If we name a student in the text, we will not use an image of that student to accompany the article. We may include pictures of students and teachers that have been drawn by the students. We may include work from students. We may use group or class images with very general labels, such as a Science lesson. We will only use images of students who are suitably dressed, to reduce the risk of such images being used inappropriately. Parents/Carers consent will be recorded on the Academys database and will be retained according to our Privacy Notice for Parents/Carers and Students. The hard copy will be retained in the students personal file. I have read and understood the above information and conditions and informed my child. 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