Admission Form - Dar-ul-Madinah Rochdale

Child's Details

First Name *

Surname *

Date of Birth *

Gender *

Class *

Address *

Postcode *

Preferred name (if any)

First Parent / Guardian

Title *

First Name *

Surname *

Relationship to Child *

Parental Responsibility

Home Telephone

Mobile *

Work Telephone

Work Place

Email

Second Parent / Guardian

Title

First Name

Surname

Relationship to Child

Address (if different)

Mobile

Email

Other children in the family (names and DOB)

Emergency Contact Details

Name of Doctor *

Doctor Telephone *

Practice Address *

Post Code *

Local contact name(s) (emergency/illness) *

Contact Telephone

Emergency Password *

Authorised persons to collect child

Person 1 – Name *

Relationship to child *

Person 2 – Name

Relationship to child

Person 3 – Name

Relationship to child

Supplementary Details

Knowledge of social services/agencies

Previous school attendance

Serious illnesses or injuries

Immunisation programme up to date

Known allergies / medical conditions

Special needs

Fears

Dietary (milk/meat/dairy)

Languages spoken at home *

Child's religion / culture *

Permissions

CCTV – I consent to CCTV recording on the premises.

Leaving premises – I give permission for my child to leave the premises when required.

Photographs – I consent to photographs being taken for school use.

First aid – I give permission for first aid to be administered when necessary.

Other helpful information

Declaration

I confirm that the details provided are accurate to the best of my knowledge.

Sign *

Date *

Print Name *

Parent / Carer *

We will process your data in accordance with our privacy policy and data protection requirements.

Review & Submit

Please review your information below. You can go back to any step to make changes, then return here to submit.