01462 623388 admin@northfields.herts.sch.uk

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Pupil Record Form

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- Step 1 of 8

Information about your child

Child's Name *

First

Middle

Last

Date of birth *

Sex *

Male
Female

Family Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

NHS number *

Parents Information

Parent/Carer 1's Name *

First

Last

Parent/Carer 1's Phone *

Parent/Carer 1's Email *

Email

Confirm Email

Parent/Carer 2's Name *

First

Last

Parent/Carer 2's Phone

Parent/Carer 2's Email

Email

Confirm Email

Address (of Parent/Carer 2 if different from family address)

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Emergency Contacts

We will always call parent/carer 1 and 2 as the first point of contact in an emergency, but should neither be contactable, we need you to provide us with at least two additional emergency contacts (therefore not including parent 1 and 2).

First Priority Emergency Contact's Name *

First

Last

First Priority Emergency Contact's Relationship to child

First Priority Emergency Contact's Email *

Email

Confirm Email

First Priority Emergency Contact's Mobile *

First Priority Emergency Contact's Home/Work Number

Second Priority Emergency Contact's Name *

First

Last

Second Priority Emergency Contact's Relationship to child

Second Priority Emergency Contact's Email *

Email

Confirm Email

Second Priority Emergency Contact's Mobile *

Second Priority Emergency Contact's Home/Work Number

Third Priority Emergency Contact's Name

First

Last

Third Priority Emergency Contact's Relationship to child

Third Priority Emergency Contact's Email

Email

Confirm Email

Third Priority Emergency Contact's Mobile

Third Priority Emergency Contact's Home/Work Number

Siblings

How many siblings does your child have? *

First Sibling *

First

Last

First Sibling's Date of Birth *

Second Sibling *

First

Last

Second Sibling's Date of Birth *

Third Sibling *

First

Last

Third Sibling's Date of Birth *

Previous Settings

Last school attended (type none if this is their first school) *

School's phone number

Preschool attended (type none if this is their first school) *

Ethnically Based Statistics on Pupils

Completion of this form is voluntary - but please help us to improve our education service by ticking the category you feel is right for your child in each of the three columns. You can get a leaflet from the school explaining in more detail how this information is used.

Ethnic Origin

White - UK
S/Asian - Indian
S/Asian - Pakistani
S/Asian - Bangladeshi
Sikh
Asian - Other
Black - African
Black - Caribbean
Black - Other
Chinese
Traveller - European
White - Other European
White - Other
Other
Unclassified

Please specify

Religion

Buddhist
Christian
Roman Catholic
Hindu
Jewish
No Religion
Sikh
Other

Please specify

Home Language

English
Bengali
Cantonese
Gujerati
Hindi
Italian
Punjabi/Gurmuki
Urdu/Punjabi
Turkish
Vietnamese
Other

Please specify

Please note - Ethnic origin is about ethnic and cultural background. It does not refer to nationality. For children of mixed race background check the relevant boxes accordingly.

Disability

Does your child have a disability or any special needs or requirements the school should be aware of? *

YES
NO

Please give details of your child's disability or special needs *

Do you consider yourself or any member of your family to have a disability or any special needs which the school need to be aware of? *

YES
NO

Please give details *

First Aid

Can we administer plasters, if necessary, to your child? *

YES
NO

Does you child have any of the following conditions? *

Asthma
Inhaler to be kept in school
Diabetes
Epilepsy
Eczema
Allergies
ADHD/ADD
Hearing impairments
Sight impairments
None of the above

If your child suffers from an allergy, please describe the reaction they have

Does your child have any special dietary requirements? *

Please tell us whether they are allergic or intolerant to certain foods or whether they are vegan/vegetarian, etc.

Name of child's GP (Doctor) *

First

Last

Surgery Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Surgery Phone Number *

Post navigation

Our address

Northfields Infants & Nursery School
Burley
Letchworth
SG6 4PT

Contact us

Need to get in touch?

01462 623388
admin@northfields.herts.sch.uk

Support for your child

senco@northfields.herts.sch.uk

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