Data Collection Form

1. Preferred Surname

2. Preferred Surname

3. Legal Surname (if different)

4. Legal Forename (if different)

5. Middle Name

6. Gender

Female

Male

7. Date of Birth

YYYY

8. Brother/Sister in School

Yes

Name(s) of Brother/Sister(s)

9. Address (Must include House Name or House Number)

10. Post Code

Parent /Guardian 1

11. Relationship to Pupil

12. Title

Mrs

13. Forename

14. Surname

15. Address

16. Postcode

17. Home Tel

18. Mobile

19. Work Tel

20. Email

Parent /Guardian 2

21. Relationship to Pupil

22. Title

Mrs

23. Forename

24. Surname

25. Address

26. Postcode

27. Home Tel

28. Mobile

29. Work Tel

30. Email

Other Contact

31. Relationship to Pupil

32. Title

Mrs

33. Forename

34. Surname

35. Home Tel

36. Mobile

Meal Arrangements

37. Meal Arrangements

Other

Home

Sandwiches

Paid School Meal

Free School Meal

38. Eligible for Free Meals

Yes

Medical

39. Medical Practice

40. Address of Medical Practice

41. Telephone

42.

Medical Information

43.

Special Dietary Needs

44. Pupil Disability

Mental & Physical Impairment

Mental Impairment

Physical Impairment

No Disability

45. Ethnicity

46. Home Language

47. Religion

48. Previously registered with a Sure Start project

Do not know

Yes

49. Attended a Sure Start Programme for 2-3 year olds

Yes

Do not know

50. Pre-School Experience

Unknown

Voluntary or private playgroup

Reception class or group in a PS

Nursery Unit within a Special School

No pre-school education setting

Nursery School or Nursery class in a PS

51. Previous School

52. Date of Admission

YYYY

53. Reason for Leaving

54. Date of Leaving

YYYY

55. Your Name *

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