Emergency Contact Form

Month and year joining *

School Year (at time of joining) *

Child's surname *

Child's forenames *

Date of birth

Home Phone

Names and ages of any brothers and sisters

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Mother's surname

(if different from above)

Mother's work number

Mother's mobile

Mother's email address *

Mother's profession

Father's surname

(if different from above)

Father's work number

Father's mobile

Father's email address *

Father's profession

Emergency contact's name (not a parent)

Please don't include parents as an emergency contact; we will always contact parents in the first instance using the details provided above.

Emergency contact's telephone

Emergency contact's mobile

2nd emergency contact's name (not a parent)

Please don't include parents as an emergency contact; we will always contact parents in the first instance using the details provided above.

2nd emergency contact's telephone

2nd emergency contact's mobile

If separated, who has legal contact with the child?

Who does your child normally live with?

Who has daily parental responsibility for the child?

CARER CONTACT DETAILS

Only complete this section if applicable

Carer's name

Carer's email address

Carer's address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Carer's home telephone

Carer's mobile

ALLERGIES & MEDICAL CONDITIONS

Medical problems *

Please put N/A if there are no issues.

Allergies *

Please put N/A if there are no issues
Letter is required from your GP to substantiate this declaration.

Special diets

Letter is required from your GP to substantiate this declaration.

Which is your child's dominant hand?

Right hand
Left hand

ACCIDENTS

Minor day to day issues e.g. scrapes and small cuts will be treated by the school staff or the school medical staff. If, however, the case is more serious and your child has to have emergency medical advice or treatment, the school will endeavour to contact you first. *

If the school is unable to contact me, I agree to my son/daughter being examined by a doctor in the case of an accident or illness and being given appropriate treatment by the doctor/consultant who has examined him / her.
If the school is unable to contact me, I do not agree to my son/daughter being examined by a doctor in the case of an accident or illness and being given appropriate treatment by the doctor/consultant who has examined him / her.

PERMISSION FOR TRIPS

During the course of a year, our pupils go on a number of trips/visits within our School Learning Area*. *

I am happy for my child to go on these visits and outings within our School Learning Area.
I am not happy for my child to go on these visits and outings within our School Learning Area.

Please note that we will notify you in advance of any trips that take place outside of this area to get your specific permission for each trip.

* The boundaries of the School Learning Area includes, but is not limited to, the following frequently used venues: Bekynton and Tor playing fields, Mundys Meadows astro turf, Wells Cathedral and Wells city centre. Please see Appendix 1 of our Educational Trips and Events Policy for full details.

PERMISSION FOR PHOTOGRAPHY

From time to time, the School photographs pupils and staff as they go about their daily routines. These photographs may be used within classrooms or within purely internal-facing documents, but will NOT appear on the School website or in any other media. *

I give permission for my son/daughter to be photographed for these reasons.
I do not give permission for my son/daughter to be photographed for these reasons.

Please see our Pupil Image Policy for further information

From time to time, the School photographs pupils for publicity purposes. These photographs may be used on the School website, in the prospectus and other publicity material, in the School magazine, in weekly bulletins and newsletters to parents, on social media, and may be sent to external media outlets (such as third party websites and newspapers) *

I give permission for my son/daughter to be photographed for press releases/social media.
I do not give permission for my son/daughter to be photographed for press releases/social media.

Please see our Pupil Image Policy for further information

Would you like your child to take part in the Whole School Photograph? *

Yes
No

CONFIDENTIALITY

The School is aware of the importance of confidentiality of telephone numbers and addresses but there are a number of occasions when we are asked for these numbers by other parents for party invitations, contact for new pupils joining the school, for compiling lists for year group reps. etc. *

I am happy for the school to give my contact number / address when requests like this are made.
I am not happy for the school to give my contact number / address when requests like this are made.

Signature *

Clear Signature

Name of signatory *

Date completed *