Read Microsoft Word - Blank Data Collection Sheet CHS.doc text version

DATA COLLECTION SHEET Please complete and return to Student Reception This information is required in case of an emergency STUDENT DETAILS: Surname: Forename: Chosen Name: Date of Birth: Legal Surname: Middle name: Gender: Reg Group: Address: Post Code: Telephone: Email:

Please give details of all persons who have parental responsibility and anyone else you wish to be contacted in case of an emergency. Place them in the order that you wish for them to be contacted in an emergency. Priority Name Relationship Parental Responsibility Contact Information ­ Home Home Addr: Yes/No Tel: Mobile: Home Email: Home Addr: Yes/No Tel: Mobile: Home Email: Home Addr: Yes/No Tel: Mobile: Home Email: Home Addr: Yes/No Tel: Mobile: Home Email: Contact Information - Work Workplace Work Addr: Work Tel: Work Email: Workplace Work Addr: Work Tel: Work Email: Workplace Work Addr: Work Tel: Work Email: Workplace Work Addr: Work Tel: Work Email:

Travel Arrangements Bicycle Route <Route> Train Car/Van

Please tick the appropriate choice Walk Taxi School Bus Car Share Public Bus Service Other

Dietary Needs Free School Meal Medical Practice: Address: Medical Condition(s): Medical Note(s): Ethnicity: Home Language:

Meal Arrangement Paid School Meal Sandwiches

Please tick the appropriate choice Home Other

Telephone Number:

Student's Main Language: Religion:

Image Consent May we use your child's photograph for display within school May we use your child's photograph in the school prospectus and other printed publications that we use for promotional purposes? May we use your child's image on our website? May we record your child's image on video or webcam? Are you happy for your child to appear in the media?

Yes/No Yes/No Yes/No Yes/No Yes/No

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 Local Authority and with the DfES. Signature: Date:

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