Application for a Nursery place at BROADHEATH PRIMARY SCHOOL

1. Personal Details.

Please complete in block Capitals

CHILD

Surname:	Other names:
Home address:
Town:	Post Code:
Date of Birth:	Gender:
Religion:	Home Language:
Ethnicity:

CHILD’S LEGAL PARENT/GUARDIAN/CARER

Surname:	Other names:
Relationship to child:
Home address:
Town:	Post Code:
Home telephone No.	Work telephone No.
Religion:	Home Language:
Ethnicity:

2. (i) Does your child have a Statement of Special Educational Needs? YES / NO

(ii) If your child has special educational needs but does not have a statement, please describe those needs.

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

(iii) What is the language spoken in the home?

________________________________

(iv) Do any other children living in a family relationship at the same address already

attend the Nursery? YES / NO

If so please give name(s)

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

3. Miscellaneous Information

Please answer all questions by writing in the box alongside each question.

3.1 State whether you would prefer your

child to attend the morning or

afternoon session. ________________________________

3.2 Is your child presently receiving any

Nursery provision? YES / NO

If yes, state name of nursery

________________________________________________________________

3.3 Does your child attend playgroup?

________________________________________________________________

3.4 Please give details of any other child care

_____________________________________________________

_____________________________________________________

NOTE: This nursery class serves all infant and primary schools in the area. Parents should note that unless they live in the catchment area for this school, there can be no guarantee of a place in the main school. However, places in the nursery class are granted without prejudice to the area in which parents live.

Signed: ___________________________________ Date: _______________

*(Legal Parent / Guardian / Foster Parent / Carer / Corporate Parent)

*Delete as appropriate

Please complete and return to:

The Headteacher of:

BROADHEATH PRIMARY SCHOOL

Sinderland Road, Broadheath, Altrincham, Cheshire, WA14 5JQ