BROADHEATH PRIMARY SCHOOL

Sinderland Road, Broadheath, Altrincham, Cheshire WA14 5JQ

Telephone: 0161-928 4748

SCHOOL ADMISSION FORM

Surname: .......................................................... Forename: ................................................................

Middle Name(s): ........................................................................

Male/Female: .................................... Date of Birth: .....................................

Address: .......................................................................................... Post Code: .....................................

Home Tel. No: ............................... Mobile No: ................................. Works Tel. No: ...........................

Contacts (in priority order):

1	Name
	Relationship to pupil
	Daytime telephone number
	Mobile telephone number
	Address

2	Name
	Relationship to pupil
	Daytime telephone number
	Mobile telephone number
	Address

3	Name
	Relationship to pupil
	Daytime telephone number
	Mobile telephone number
	Address

Meal Arrangement (please tick the appropriate choice)

o Sandwiches

Doctor: ......................................................................................................................................................

Address: ................................................................................. Telephone No: .......................................

Medical Information: ...............................................................................................................................

Permission to put on a Plaster: .................................................................................................................

Name and Address of Previous School:
Date of Application:	Date of Admission:

Ethnic Background:

Please study the list below and tick one box only to indicate the ethnic background of the pupil or child named over. Our ethnic background describes how we think of ourselves. This may be based on many things, including, for example, our skin colour, language, culture, ancestry or family history. Ethnic background is not the same as nationality or country of birth.

White

o British

o Irish

o Traveller of Irish Heritage

o Gypsy/Roma

o Any other White background

Mixed

o White and Black Caribbean

o White and Black African

o White and Asian

o Any other mixed background

Asian or Asian British

o Indian

o Pakistani

o Bangladeshi

o Any other Asian background

Black or Black British

o Caribbean

o African

o Any other Black background

Chinese

o

Any other ethnic background

o

o I do not wish an ethnic background category to be recorded

Home Language:

Religion:

Signature of Parent or Guardian: ................................................................................................