Data Collection Form

Surname* Legal Surname* Forename* Middle Name(s) Chosen Name Gender* Date of Birth* Year and Tutor Group* Address (Line 1)* Address (Line 2) Town/City* Post Code* Home Telephone*

The following information is optional but is useful for the Academy in supporting your child whilst here at the Academy.

Ethnicity Religion First Language: Home Language Country of Birth Nationality

Please give details of all persons who have parental responsibility and anyone else you wish to be contacted in an emergency.

Place them in the order that you wish for them to be contacted in an emergency and provide a minimum of 2 contact persons:

Priority 1

Relationship to Student* Forename* Surname* Email Address* Home Telephone* Work Telephone* Mobile* Home Address* Post Code*

Priority 2

Relationship to Student Forename Surname Email Address Home Telephone Work Telephone Mobile Home Address Post Code

Priority 3

Relationship to Student Forename Surname Email Address Home Telephone Work Telephone Mobile Home Address Post Code

Dietary Information

Please note here any dietary requirements including dietary preferences

Medical Information

Please note here any medical conditions Medical Practice Telephone Address

Please provide details of any medication
	Name of medication	Dosage	Times of day or circumstances to be given	Method of administration

Any special precautions, side effects or medication etc

Consent: Extra-curricular activities and School visits

Please tick the relevant box(es) below and return this form to school.I agree to my child taking part in extra-curricular and careers based activities and school visits and agree to his/her participation.I acknowledge the need for obedience and responsible behaviour on his/her part – this includes zero tolerance of the use of any banned substance/alcohol.I understand that there is some level of risk in every activity but that activities will be managed to minimise the risks involved.I understand the extent and limitations of the insurance cover provided.I give permission for my child to be included in the collective passport to be held by the group leader

If there are any activities in which your child cannot participate, please give details

Please tickIf water activities are involved, my child is confident in water?

Please be sure to include any conditions that your child suffers from, that we would need to be aware of on school visits / extra-

curricular activities in the medical sections further on this form.

Please tickI give my consent for a member of staff to administer the medication listed above on this form if necessary, which I will deliver to the group leader before the visit. I understand the staff leading the visit are not qualified medical practitioners but are first aid trained and that they will take reasonable care in the administration of the medication and will endeavour to respond appropriately should emergency treatment be required.I give my consent for my child to self-administer the medication listed above on this form.

Consent

Please tickI agree to inform the Academy of any updates to the information provided within this form, in particular medical information or other circumstance. I understand that this will remain in effect until my child reaches the end of Y11.I agree to my child receiving emergency medical treatment. In the event of the school being unable to contact me in an emergency, on the school premises or whilst on an off-site visit, I agree to my child receiving emergency treatment, including anaesthetic and blood transfusion, as considered necessary by the medical authorities present.PARENT PAY/BIOMETRIC Consent - Having read the Parent Pay information provided to me by the Brunts Academy, I give consent to information from the fingerprint of my child being taken and used by the Brunts Academy for use as part of an automated biometric recognition system for the purpose of paying for items from the school canteen. I understand that I can withdraw this consent at any time in writing.EMERGENCY CLOSURE – I consent to my child’s release from school in the event of an emergency school closure.I understand that the information I have provided will be used in compliance with the Greenwood Academies Trust/Academy’s GDPR procedures.

Signature

Please sign (complete the boxes below) to confirm that you have checked, amended and now agree that the information provided is accurate and that the option you selected with regard to taking part in extra-curricular activities and school visits is correct.

Name of parent/carer* Relationship to Student

Signature Confirmation*I agree that the information provided is accurate

Date*