Registration form for new students, who have been offered a place at Heartlands Academy Registration form for new students, who have been offered a place at Heartlands Academy Use this form to register new students who have received an offer for a place at Heartlands Academy. Step 1 of 22 4% 1: Student informationStudent name First name(s) Surname/Family name Gender Female Male Date of birth DD slash MM slash YYYY Nationality Number of years resident in UK Email Enter Email Confirm Email Address Street Address Address Line 2 City County Post Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home phone numberMobile phone numberMost recent school attended School name Street address City County Post Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country What is your child's first language? 2: Special Educational Needs and DisabilityDoes your child have a statement of Special Educational Needs and Disability (SEND)* Yes No Don't know Is your child on any of the following registers? SEND Register Stage School Action Plan School Action Plus None 3: Emergency ContactIt is essential that we are able to contact you during the day in case of an emergency. If we are unable to contact you at home or at work, please give us a name, relationship and number where emergency contact can be made. Note: Contact will be made in case of an emergency.Emergency contact name First name(s) Surname/Family name Relationship (eg grandparent, neighbour etc) Home address Street Address Address Line 2 City County Post Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Work telephone numberHome telephone numberMobile telephone number 4: Parent / Carer information and contact detailsParent(s)/Carer(s) (person(s) with legal parental responsibility)First contact name First name(s) Surname/Family name Date of birth DD slash MM slash YYYY Occupation Place of workNational Insurance Number Email Home address (if different from child's) Street Address Address Line 2 City County Post Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Work telephone numberHome telephone numberMobile telephone numberLanguage spoken at home Do you require a translator? Yes No Second contact name First name(s) Surname/Family name Date of birth DD slash MM slash YYYY Occupation Place of workNational Insurance Number Email Home address (if different from child's) Street Address Address Line 2 City County Post Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Work telephone numberHome telephone numberMobile telephone numberLanguage spoken at home Do you require a translator? Yes No 5: Brothers and SistersPlease list all brothers and sisters and state their age and which school they currently attend. 6: School mealsWill you child: Require a school meal from the dining hall? Bring a packed lunch? Does your child have any dietary requirements? Halal Vegetarian Vegan Allergies Other If you selected 'allergies' or 'other' above, please detail below Is your child entitled to free school meals? Yes No Don't know Parents can now check their eligibility for Free School Meals online at: www.cloudforedu.org.uk/ofsm/birmingham.We are able to check your eligibility for Free School Meals on your behalf. Do we have your permission to do this? Yes No Please ensure that you have provided your National Insurance number and date of birth on Section 4. 7: HolidaysDo you have any extended holidays abroad or other long absences planned? Yes No Please provide details below. 8: Travel arrangementsPlease indicate how your child will travel to the academy. Walk Cycle Public transport Motor vehicle (eg car) 9: Additional informationPlease write down any other information which you think the academy should have. Eg any concerns you may have or special requests. 10: Data Protection Act 1998The information collected will be processed in compliance with the Data Protection Act 1998. It will be used to administer your child's progress through the education system and may be shared with the Department for Education, Local Authority, other schools and educational establishments to which your child may progress, future and prospective employers, health and welfare practitioners and Connexions. Connexions are entitled by law to receive details of pupils' and parents' names and addresses but often find additional information beneficial when dealing with pupils. If you do not wish additional data to be disclosed to Connexions please notify us in writing, otherwise, we will assume we have your consent to disclose additional relevant information.Consent I agree to my information to be collected and processed in compliance with the Data Protection Act 1998. 11: Medical informationName of your child's doctor Doctor's address Street Address Address Line 2 City County Post Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Doctor's telephone numberIs your child under hospital care for anything? Yes No Which hospital? Name of consultant Does your child need to wear glasses? Yes No Does your child have any hearing difficulties? Yes No Does your child suffer from asthma? Yes No Does your child have an inhaler? Blue inhaler Brown inhaler None Please give details of anything which triggers your child's asthma.Does your child have diabetes? Yes No Which hospital is your child's care under? Does your child have epilepsy? Yes No Which hospital is your child's care under? Does your child have any allergies? Yes No What is your child allergic to?What emergency treatment (if any) has been prescribed?Does your child have any physical or mobility difficulties which may cause problems at the academy? Yes No Please give detailsFrom time to time, it may help your child to take paracetamol for a mild headache or pain: this can be administered with parental consent.Paracetamol consent I give consent for my child to take a paracetamol. 12: Health questionnaireAs your child is new to Heartlands Academy, we would be grateful if you would complete this questionnaire. The aim of the questionnaire is to identify any possible health needs that may affect your child's ability to achieve in school. All information recorded on the questionnaire will remain confidential.Child's name First name(s) Surname/Family name Child's date of birth DD slash MM slash YYYY School Language(s) spoken Ethnicity Parent/carer's telephone numberDate completed DD slash MM slash YYYY 13: Are you concerned about any of the following health issues?Any medical conditions which may affect the child/young person in school such as allergies or asthma? Yes No Details of health concernsConcerns about the child/young person's emotional health issues, such as anxiety, self-harm, behaviour? Yes No Details of health concernConcerns about the child/young person's weight or diet? Yes No Details of health concern.Concerns about the child/young person's sexual health or relationships? Yes No Details of health concern?Is the child/young person using drugs, or alcohol, or smokes? Yes No Details of health concernChild/young person is NOT up to date with vaccinations (please check with your family doctor). Yes No Details of health concernProblems with enuresis (bed wetting). Yes No Details of health concern 14: Photography consentE-ACT uses photographs and videos of students and parents in lots of different ways. Because we consider that using photographs and videos in the following ways is more privacy intrusive, we are asking for your consent for this first. I/we consent to E-ACT: Publishing photographs and videos on the E-ACT website and on the website of Heartlands Academy. Publishing photographs and videos on social media. Publishing extra information alongside photographs and videos such as student names and evidence of achievements. This applies to website, social media and printed material. Allowing my child's name and photograph to appear in a local newspaper, for example, in connection with a story about Heartlands academy. There is no obligation on you to consent if you don't want to. If you change your mind, you can withdraw your consent by informing Heartlands Academy. If you do withdraw your consent, we will do what we can to stop using the photograph(s) or video(s) as soon as possible e.g. remove it from our website. However, for certain uses, this will not be possible e.g. where it has been published in our prospectus and the prospectus has been printed and is currently in circulation. For more information about how E-ACT may use your/your child's information, please see our pupil and parent privacy notices, which are published on the E-ACT website: bannerxe.thisweekonlot.com. 15: Heartlands Academy AgreementHeartlands Academy will: Provide a safe, well ordered and careing environment. Expect all student to achieve their personal best and develop in them a responsibility for their own lifelong learning. Encourage high standards of work and behaviour through building good relationships and developing a sense of responsibility and ensuring that all students follow Heartland Academy's behaviour policy. Provide a high standard of teaching, in line with the requirements of the National Curriculum, including the setting and marking of challenging class and homework. Challenge unacceptable behaviour wherever it occurs. Value and respect all cultures. Acknowledge the important role that parents and carers maintain in the life of their child and reinforce that role with the students. Work to communicate with all parents/carers consistently so that, so that they are aware of classroom activities, their child's involvement, and how they can participate. Ensure that all parents know how to contact the academy, emphasize that communication is important in helping their child succeed and make staff available to meet parents where appropriate. Ensure that if problems arise, the academy will communicate immediately with parents and carers and include the positive activities in which the student is engaged. Keep you informed through regular letters about special events. Provide a range of extra-curricular activities. Praise and reward achievements and use appropriate sanctions where necessary. Provide quality careers guidance and advice. Provide ICT protection, training and advice to prevent access to inappropriate material, in line with national guidelines. 16: Parent/carer agreementParental agreement* I have chosen to send my child to Heartlands Academy, therefore I/we agree to: Encourage my child to do well in the academy and be a good citizen in the classroom, respecting teachers, academy staff, and other students. Encourage my child to respect the academy environment and its community and support the Code of Conduct. Maintain an environment and schedule at home that fosters learning and ensures that my child will attend school regularly and on time, with the ability to learn and actively participate in academy activities. Inform the academy promptly of the reasons for any absence, avoiding where possible, appointments and holidays in school time. Ensure my/our child has all the necessary uniform and equipment. Communicate with my child's teacher any circumstances that would directly affect my child's ability to learn as early as possible. Provide up to date contact information as soon as possible. Support my/our child in homework and other learning opportunities. Attend parents' evenings and review days to discuss my/our child's progress. Read all correspondence from the academy and promptly respond to any requests from a teacher or member of staff concerning the wellbeing and educational activities of my child. Make myself knowledgeable concerning the education standards set for the year and subject matter for my child and be continually aware of the current status of my child's work. Support Heartland Academy's policies and guidelines. 17: Student agreementStudent agreement* As a student of Heartlands Academy, I will: Attend the academy regularly and on time. Be organised, well equipped and wear the correct uniform. Try to work hard and do my very best on all assigned learning activities, including classwork, homework, and coursework. Show respect for my teacher, academy staff, and fellow students. I will understand academy regulations and follow academy rules and the Code of Conduct, treating the academy building and community with care. Look after the academy environment and take responsibility for keeping it clean and tidy. Use my planner effectively and share it with my parents. Make sure that any messages between my teacher and parents are given to them as soon as possible. Passing letters to my parents. Value the opportunity to learn. Attend any detentions, or serve any other sanction which is issued to me. Not attempt to use ICT facilities inappropriately, divulge my passwords to others, or disable protective software. Abide by the rules regarding the use of my mobile phone, or other electronic devices. Attend parents' evenings and be part of the meeting, in order to make sure that I am learning the skills that are necessary for my success. Welcome any visitors to the academy and my class and thank them for their work with students. I will contribute my individual talents to making my academy community better. Complete any duties with which I am issued as part of the academy community e.g. prefect duty. 18: Ethnic monitoringPlease select which one best describes your daughter's/son's ethnic group.Ethnic origin*White BritishAny other white backgroundMixed dual backgroundAsian or Asian BritishBlack or black BritishAny other ethnic groupRefuse - I do not want ethnic origin to be recordedWhite BritishEnglishScottishWelshOther White BritishIrishTraveller of Irish HeritageCornishGypsy/RomaI do not want ethnic origin to be recordedAny other white backgroundAlbanianBosnian - HerzegovinianCroatianGreekGreek CypriotItalianKosovanPortugeseSerbianTurkishTurkish CypriotWhite Eastern EuropeanWhite Western EuropeanWhite otherI do not want ethic origin to be recordedMixed dual backgroundWhite & black CaribbeanWhite & black AfricanWhite & PakistaniWhite & IndianWhite & any other Asian backgroundAsian and any other ethnic groupAsian & blackAsian & ChineseBlack & any other ethnic groupBlack & ChineseChinese & any other ethnic groupWhite & any other ethnic groupWhite & ChineseMixed any other backgroundI do not want ethnic origin to be recordedAsian or Asian BritishIndianBangladeshiMirpuri PakistaniOther PakistaniKashmiri PakistaniAfrican AsianKashmiri otherNepaliSri Lankan SinhaleseSri Lankan TamilSri Lankan otherOther AsianHong Kong ChineseMalaysian ChineseSingaporean ChineseTaiwaneseOther ChineseI do not want ethnic monitoring to be recordedBlack or black BritishCaribbeanAngolanCongoleseGhanaianNigerianSierra LeonianSomalianSudaneseOther black AfricanBlack EuropeanBlack North AmericanOther blackI do not want ethnic origin to be recordedAny other ethnic groupAfganArabEgyptianFilipinoIranianIraqiJapaneseKoreanKurdishLatin/South/Central AmericanLebaneseLibyanMalayMoroccanPolynesianThaiVietnameseYemeniAny other ethnic groupI do not want ethnic origin to be recorded 19: Ethnic monitoringPlease select which one best describes your daughter's/son's religious affiliation.Ethnic originBuddhistChristianChristian - Roman CatholicHinduJewishMuslimNo religionSikhAny otherI do not want religion to be recordedIf you selected 'any other' above, please describe below: 20: Ethnic monitoringPlease select which best describes the main language used at home or in the community: (Please note the list is of the most commonly spoken languages in Birmingham and is for guidance only. If your language is not listed below, please select "any other" and describe it in the space provided.)First/home languageAfrikaansAlbanian/ShqipArabic (Iraq)Arabic (Yemen)Arabic (any other)Bengali (Sylheti)Bengali (any other)BosnianBritish sign languageCaribbean - Creole/PatoisChinese (Cantonese)Chinese (Hakka)Chinese (Mandarin)Chinese (any other)CroatianCzecDanishDutch/FlemishEnglishFilipinoFrenchGermanGreekGujaratiHindiHindkoHungarianIgboItalianKashmiriKoreanKurdishLingalaMalay/IndonesianMalayalamNorwegianPahari (Pakistani)Panjabi (Gurmukhi)Panjabi (Mirpuri)Panjabi (Polhwarl)Panjabi (any other)Pashto/PakhtoFarsi/Dari/PersianPolishPortugeseRomanianRussianSamoanSerbianShonaSlovakSomaliSpanishSwahili/KiswahiliSwedishTagalogTamilTeluguThaiTigrinyaTurkishUrduVietnameseWelsh/CymraegWolofYorubaZuluAny otherI do not want first language to be recordedIf you selected 'any other' above, please describe below: 21: Ethnic monitoringWe need to know your child's country of birth and nationality, which may be different. Therefore, please select from both of the dropdowns below. Thank you.Country of birthAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Antarctic TerritoryBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurmaBurundiByelorussian SSRCameroonCanadaCanton and Enderbury IslandsCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo, Democratic RepublicCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicCzechoslovakiaDahomeyDemocratic YemenDenmarkDjiboutiDominicaDominican RepublicDronning Maud LandEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesFrench Territory of Afars and IssasGabonGambia, TheGeorgiaGerman Democratic RepublicGermanyGhanaGibraltarGilbert and Ellice IslandsGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Islands and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJohnston AtollJordanKampucheaKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMidway IslandsMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew HebridesNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayNot knownNot yet obtainedOmanPakistanPalauPalestinePanamaPanama Canal ZonePapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRefusedReunionRomaniaRussiaRwandaSaint BarthelemySaint Kitts-Nevis-AnguillaSaint LuciaSaint Martin (French Part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSerbia and MontenegroSeychellesSierra LeoneSikkimSingaporeSint Maarten (Dutch Part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth SudanSouth VietnamSouthern RhodesiaSpainSri LankaSt Helena, Ascension and Tristan da CunhaStatelessSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTrust Territory of the Pacific IslandsTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkrainian SSRUnion of Soviet Socialist RepublicsUnited Arab EmiratesUnited KingdomUnited States of AmericaUnited States Minor Outlying IslandsUnited States Miscellaneous Pacific IslandsUpper VoltaUruguayUzbekistanVanuatuVatican City StateVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wake IslandWallis and FutunaWestern SaharaYemenZaireZambiaZimbabweCountry of nationalityAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Antarctic TerritoryBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurmaBurundiByelorussian SSRCameroonCanadaCanton and Enderbury IslandsCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo, Democratic RepublicCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicCzechoslovakiaDahomeyDemocratic YemenDenmarkDjiboutiDominicaDominican RepublicDronning Maud LandEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesFrench Territory of Afars and IssasGabonGambia, TheGeorgiaGerman Democratic RepublicGermanyGhanaGibraltarGilbert and Ellice IslandsGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Islands and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJohnston AtollJordanKampucheaKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMidway IslandsMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew HebridesNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayNot knownNot yet obtainedOmanPakistanPalauPalestinePanamaPanama Canal ZonePapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRefusedReunionRomaniaRussiaRwandaSaint BarthelemySaint Kitts-Nevis-AnguillaSaint LuciaSaint Martin (French Part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSerbia and MontenegroSeychellesSierra LeoneSikkimSingaporeSint Maarten (Dutch Part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth SudanSouth VietnamSouthern RhodesiaSpainSri LankaSt Helena, Ascension and Tristan da CunhaStatelessSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTrust Territory of the Pacific IslandsTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkrainian SSRUnion of Soviet Socialist RepublicsUnited Arab EmiratesUnited KingdomUnited States of AmericaUnited States Minor Outlying IslandsUnited States Miscellaneous Pacific IslandsUpper VoltaUruguayUzbekistanVanuatuVatican City StateVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wake IslandWallis and FutunaWestern SaharaYemenZaireZambiaZimbabwe 22: Confirmation and submitFeel free to use the back button to check that all of the information entered is correct. Once ready, please use the 'submit' button below to send your completed application to us.Confirmation I confirm that all of the information given here is correct, to the best of my knowledge.PhoneThis field is for validation purposes and should be left unchanged.
