Pupil Admission Form

Pupil Admission Form

Tower Learning Centre Independent School DFE No: 890/6010.

Complete the form in as much detail as possible, any missing information could result iin an admissions delay.

If you require any assistance completing this form, please contact the main office on 01253290949

Roll Type

Single - (Full Time)

Dual Roll - Subsidiary

If Dual Roll

You MUST state the length of time you wish the young person to attended TLCIS. This can be extended or reduced in accordance to the young persons progress, if needed.

Reason for referral*

Select or enter value

Address*

Street name and town

Ethnicity*

Select or enter value

Year Group*

Year 10

Year 11

Last School

Current or last school attended

Parent/Carer Details

Name of Main Parent/Carer*

Relationship with Pupil*

Home Address (including postcode)

Parent/Carer Contact Numbers*

Please provide current home and mobile numbers

Parent/Carer Email Address*

Are Parents/Carers aware of the referral?*

Yes

Have Parents/Carers agreed to support the referral?*

Yes

School, Agency or Care Organisation*

Please provide details below

Agency Key Contact Name*

Please provide main contact within your organisation that is responsible for the referred pupil

Key Contact Email Address*

Attendance Officer Name*

Person to receive attendance information about your pupil.

Attendance Officer Email Address*

Attendance Officer Contact Number*

DBS Information

Please provide DBS numbers for any supporting staff that will be required to attend the School for support and monitoring purposes.

Travel Arrangements*

Will the pupil require transport to and from the School for attendance purposes?

Yes

Travel Responsibility*

Which school or agency will be responsible for providing transport and the cost incurred?

Emergency Contact Details

Please provide details of 2 named people who would be suitable to contact in an the event of an emergency In the unlikely event of an emergency and our inability to contact any of your emergency contact(s), we will seek appropriate medical help e.g. ambulance. Medical help may also consist of use of a private vehicle to accompany the student to hospital, if advised by a medical practitioner.

Emergency Main Contact Name*

(Compulsory requirement)

Relationship to Pupil*

Main Emergency Contact Mobile Phone Number*

(Compulsory requirement)

Emergency Contact Email Address*

Secondary Emergency Contact Name*

(Compulsory requirement)

Relationship to Pupil*

Secondary Emergency Contact Phone Number*

(Compulsory requirement)

Safeguarding and Support

I understand that information held about the named student is in a secure and encrypted environment and acknowledge the implications of sharing or not sharing information. Should you have any questions, please contact Natalie Partington at natalie@tower-learning.co.uk (Designated Safeguarding Lead)

Exclusion History*

Provide details of any exclusion history over the last 12 months from current or previous school or organisation

Reason(s) for Previous Exclusions*

Risk Assessment*

Does the pupil being referred have a current assessment? If yes, this will be requested before any possible start date is agreed

Yes

Health, Safety and Welfare*

Please specify any know issues that student suffers from

Select or enter value

Pupil Social Profile

Agency Involvement*

Please specify below

Select or enter value

Agency Information

Please specify the level and support being offered by the support agency(s)

Current Status*

Does the pupil fall in to a vulnerable group?

Select or enter value

SEN/IEP/DSL Information

Name of School's DSL

Safeguarding Folder Attached?*

Yes

Education Health Care Plan (EHCP)*

Does the referred named student named in this referral have a current EHCP?

Yes

File Upload

Upload any supporting documentation or email securely to admin@tower-learning.co.uk

Drag and drop files here or

PEP in Place? Date of last PEP*

EP Report Attached?*

Barriers to Learning/Education

Please choose those barriers that are relevant to the young person being referred

Barriers to Education*

Select or enter value

Personal and Social Development*

Select or enter value

Positive Family and Home Life*

Select or enter value

Details of Medication*

Details of any medication taken on a daily basis

Skills profile

Please rate the pupil's skills in the following areas (1) Excellent to (4) Poor

Time Keeping*

Interaction With Other Pupils*

Interaction With Teachers*

Lesson Behaviour*

Attitude Towards Home Life or Current Situation*

Physical Challenging Behaviour*

Have there been any instances of Physical Challenging Behaviour that have resulted in harm or distress to another pupil, teacher or staff member?

Yes

Details from above (if 3 to 5

Give full details:

Risk to Property*

Have there been any instances of property damage or concerns raised against the child named on this form?

Yes

Damage to Property*

How likely is this going to happen? (1 Unlikely- 5 likely)

Select or enter value

Details for above (if 3 to 5)

Give full details

The School Day

Morning Registration/Form 9.-9.30 Lesson 1 - 9.30-10.45 Break- 10.45-11.00 Lesson 2- 11.00-12.10 Lunch- 12.10-12.35 Afternoon Lesson 3- 12.35-1.30 Lesson 4- 1.30-2.30 School Day Finishes 2.30pm

School Meal*

Please select if the pupil requires a meal a lunch time

Free (paid for by referring school or agency)

Own cost

Will provide their own food

Summary of main reason for referral/support requested at Tower Learning Centre Independent School*

Funding

Please provide details of the organisation and person who has approved funding for the person being referred

Organisation Responsible for funding*

Name of Person that has Approved Funding*

Invoicing

Please provide details of the organisation and person responsible for the processing of invoices

Organisation responsible for the processing of invoices*

Name of person*

responsible for processing the invoice

Email address for invoicing purposes*

Please provide your finance department email address for invoicing purposes

Permission*

I hereby give my permission to share additional information with Tower Learning Centre Independent School in connection with supporting educational provision for the young person named in this referral pack. This could include one or more of the following (please tick)

Select or enter value

Declaration*

I agree that all information provided in this form is accurate and factual and have the authorisation to complete and refer the young person to Tower Learning Centre.

Send me a copy of my responses

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Pupil Information

Parent/Carer Details

Referrer Details

Emergency Contact Details

Safeguarding and Support

Pupil Social Profile

SEN/IEP/DSL Information

Barriers to Learning/Education

Skills profile

The School Day

Funding

Invoicing