Emergency Contact & Welfare Profile

Before completing this form, you may wish to have the following information to hand:

Electronic copy of pupil’s birth certificate and passport (pdf or jpeg format)
Current/previous school address and contact information
GP or allergy specialist clinic address and contact information

And if applicable:

Medical prescriptions (including valid expiry dates)
Electronic copy of any EHC and/or SEN recent, relevant professional reports concerning your child, such as occupational therapy, speech therapy, educational psychology, specialist teacher, CAHMS, etc. (pdf or jpeg format)

Please complete all sections clearly and refer to the Guidance Notes and the Data Protection Policy before beginning:

REVIEW GUIDANCE NOTES
REVIEW DATA PROTECTION POLICY

SELECT SCHOOL

School*

BIRTH CERTIFICATE AND/OR PASSPORT

We must have proof of identification to register your child – please upload either a PDF or JPEG photocopy or scan of your child’s birth certificate or passport:

Upload Birth Certificate

Upload Passport

Section A: Basic Details

Child’s Legal Forename (first name on birth certificate)*

Does the child have a legal middle name?*

Child’s Legal Surname (last name on birth certificate)*

Child’s Preferred Forename

Child’s Preferred Middle name

Child’s Preferred Surname

Gender* Male Female

Date of Birth*

RESIDENTIAL ADDRESS:

Address 1*

Address 2

Address 3

Town*

County*

Postcode*

SIBLING DETAILS:

If you already have a child within the School, please provide the following information:

Does the child have a sibling enrolled in the school?*

Section B: Parental Consent for Biometric and Cashless Catering Reading

(PLEASE SEE GUIDANCE NOTES FOR FURTHER INFORMATION)

The school uses Biometric readings for cashless catering and other services. This system has significantly improved the services offered to students and staff, with benefits including:

Reduction in queuing time in the school cafe.
Children will not have to remember a PIN or to bring a card.

In order for your child to use the biometric system, one parent or guardian will need to sign below

Signature of Parent/Carer*

Is your consent given?*

Section C: Family/Home Contact Details

PLEASE REFER TO THE GUIDANCE NOTES WHEN COMPLETING THIS SECTION – PARENTAL RESPONSIBILITY AS DEFINED BY THE CHILDREN’S ACT 1989:

Who Is a "Parent"?

Section 576 of the Education Act 1996 deﬁnes parent as:

All natural parents, whether they are married or not;
Any person who, although not a natural parent, has parental responsibility for a child or young person;

Having parental responsibility means assuming all rights, duties, powers, responsibilities and authority that a parent of a child has by law. People other than a child's natural parents can (only) acquire parental responsibility through:

Being granted a residence order
Being appointed a guardian
Being named in an emergency protection order (although parental responsibility in such a case is limited to taking reasonable steps to safeguard or promote the child’s welfare)
Adopting a child

In addition a local authority can acquire parental responsibility it it is named in the care order for a child.

CONTACT 1 (PRIORITY 1) PARENT/LEGAL GUARDIAN:

This needs to be a Parent or Legal Guardian and is the first person the school would contact in an emergency. This contact would automatically receive all communications sent out by the school from notifications relating to the students studies, school news and postal communications i.e. Termly Reports.

Relationship to child*

Confirm Legal Parental responsibility*

The Primary contact receives all school communications automatically

Title*

Parent/Carer Forename*

Parent/Carer Surname*

ADDRESS

Address same as child’s?*

CONTACT

Mobile Number*

Daytime/Work number*

Home Number*

EMAIL ADDRESS: This email address will be used to send school communications to you

Email address* Confirm email address*

Type* Home Work

Alternate email which would only be used if there was a problem with the one above:

Alternative email address Confirm email address

Type Home Work

CONTACT 2 (PRIORITY 2):

If the school was unable to reach the Primary Contact this is the next contact they would ring.

Relationship to child*

Legal Parental responsibility

Title*

Forename*

Surname*

ADDRESS

Address same as child’s?*

CONTACT

Mobile Number*

Daytime/Work number

Home Number

CONTACT 3 (PRIORITY 3):

If the school was unable to reach the Secondary Contact this is the next contact they would ring.

Relationship to child

Legal Parental responsibility

Title

Forename

Surname

ADDRESS

Address same as child’s?

CONTACT

Mobile Number

Daytime/Work number

Home Number

Section D: Ethnic/Cultural

Any information you provide will be used solely to compile statistics on the school careers and experiences of pupils from different ethnic backgrounds, to help ensure that all pupils have the opportunity to fulﬁl their potential. These statistics will not allow individual pupils to be identified. From time to time the information will be passed on to the Local Education Authority and the Department for Education (DfE) to contribute to local and national statistics, the information will also be passed on to future schools, to save it having to be asked for again.

Any information that we receive from legal documents, such as passports and birth certiﬁcates, is not used to verify information in this section. We will record all ethnic and cultural information as declared by you in the tables below.

Country of Birth

Nationality

Ethnic origin

Other

Religion

Other

Language (First Language spoken)

Other

Section E: Additional Information

Current School*

Address 1*

Address 2

Address 3

Town*

County*

Postcode*

From*

To*

My child has a valid Education, Health & Care Plan (previously known as a Statement):*

My child received additional support at their previous School:*

If selected ‘Yes’ for either an EHC Plan or Additional Support, you will need please upload a photocopy of any recent, relevant professional reports concerning your child, such as occupational therapy, speech therapy, educational psychology, specialist teacher, CAHMS, etc. here:

Borough to whom you pay Council Tax*

Travel arrangements*

Section F: Welfare (First Aid & Dietary)

Who is responsible in an emergency?*

If different for off-site activities, please specify:

GENERAL PRACTITIONER/CLINIC CONTACT

General Practice Surgery*

Surgery contact number*

Address 1*

Address 2

Address 3

Town*

County*

Postcode*

DIETARY REQUIREMENTS

KNOWN MEDICAL CONDITIONS AND/OR SYMPTOMS

No known medical conditions or symptoms

Anaphylaxis

My child has been diagnosed with anaphylaxis and has been prescribed an epi-pen:*

My child uses an inhaler for anaphylaxis (please refer to the Asthma section parents and carers are required to complete the Asthma section as well):*

My child has a working, in-date epi-pen, clearly labelled with their name, which will be stored in Reception or the Welfare Office or in extreme cases, for the pupil to carry on-hard at all times:*

In the event of my child displaying symptoms of anaphylaxis and if their epi-pen is not available or is unusable, I consent for my child to receive epinephrine from an emergency epi-pen held by the school for such emergencies:*

Prescription*

Prescription expiry date*

Does your child tell you when he/she needs medicine?*

Does your child need help taking his/her asthma medicines?*

Dosage instructions*

Does your child need to take medicines before exercise or play?*

My child has an allergy specialist:*

Description of individual severe allergies and symptoms (signs which indicate that your child is having an attack):*

Description of individual mild allergies and symptoms:*

Reliever treatment when needed (for shortness of breath, sudden tightness in the chest, wheeze or cough, give or allow my child to take the medicines listed above) and after treatment (e.g. as soon as they feel well they can return to normal activity):*

Daily care requirements (e.g. before sports and/or at lunchtime):*

Describe what constitutes as an emergency to the pupil, actions to be taken and follow-up care:*

GENERAL WELFARE POLICY

It is the parents and carers responsibility to review all welfare details each academic year or according to need. The School should be updated as and when your child’s treatment changes. Medicines provided should be clearly labelled (Chemist/Pharmacy labels only) with your child’s name and valid expiry date to be kept in agreement with the School’s policy, PRIOR TO YOUR CHILD’S START DATE.

Staff Indemnity:

Ealing Council fully indemnifies its staff against claims for alleged negligence, providing they are acting within the scope of their employment, having been provided adequate training, and are following the LEA’s guidelines. For purposes of indemnity, the administration of medicines falls within this definition and hence the staff can be reassured about the protection their employer provides. The indemnity would cover the consequences that might arise where an incorrect dose is advertently given or where the administration is overlooked. In practice indemnity means that the Ealing Council and not the employee will meet the cost of damages should a claim for alleged negligence be successful. It is very rare for school staff to be sued for negligence and instead the action will usually be between the parent and employer.

Agreement and Conclusion:

The school and parent will hold a copy of these notes. Copies should be sent to the G.P., allergy specialist and Local Educational Authorities for information.
Any necessary revising will be the subject of further discussions between the school and parents.
On a termly basis, any change in routine will be noted and circulated.
It is the parent’s responsibility to ensure medications are available for the School and replaced before the expiry date indicated on the label.

DOWNLOAD & PRINT POLICY

I can confirm that I have read and understood the First Aid and Support for Students with Medical Conditions Policy.

Should you have any queries or concerns in regards to your child’s welfare and potential treatment plan, please contact the Welfare Office.

Section G: Signature of Consent

To acknowledge that you have read and understood the Trust Privacy Notice – Data Protection Act 1998 & General Data Protection Regulation (EU 2016/679) (GDPR) and the Trust Guidance Notes for Completing an Emergency Contact & Welfare Profile, as well as any other relevant legislation and/or school policies relating to your child’s enrolment and/or welfare, please provide your signature of consent as well as the date signed:

Signature of Parent/Carer Consent*

Relationship to child*

Date*

Emergency Contact & Welfare Profile

SELECT SCHOOL

BIRTH CERTIFICATE AND/OR PASSPORT

Section A: Basic Details

RESIDENTIAL ADDRESS:

SIBLING DETAILS:

Section B: Parental Consent for Biometric and Cashless Catering Reading

Section C: Family/Home Contact Details

CONTACT 1 (PRIORITY 1) PARENT/LEGAL GUARDIAN:

CONTACT 2 (PRIORITY 2):

CONTACT 3 (PRIORITY 3):

Section D: Ethnic/Cultural

Section E: Additional Information

Section F: Welfare (First Aid & Dietary)

GENERAL PRACTITIONER/CLINIC CONTACT

DIETARY REQUIREMENTS

KNOWN MEDICAL CONDITIONS AND/OR SYMPTOMS

Asthma

Anaphylaxis

Diabetes

Epilepsy

General allergies

Other condition

GENERAL WELFARE POLICY

Section G: Signature of Consent