Confidential Information Form | Mount House School

1. Student Details

Child Name *

First

Last

Year Group on entry *

2. About your child:

Please confirm whether your child has: *

Learning difficulty or special educational need(s)
EHCP (educational health care plan)
Disability
Behavioural, emotional and / or social difficulty
Historic or on-going safeguarding issue
None of the above

if not applicable, Please select 'none of the above' option.

If you have selected one of the above, please provide more detail:

Please provide any relevant documentation such as assessment reports or EHCP to the email: admissions@mounthouse.org.uk

3. Medical

Does your child have any medical conditions? *

If no, go to 4. Dietary

If yes, please select the medical type

Please select Allergy type

Bites/Stings
Environmental
Food

Please specify allergy

Please select Condition type

Asthma
Diabetes
Epilepsy
Other

If selected 'other', state condition(s) here:

Does this allergy or condition require use of inhaler/ auto injector or medication? (Provide details)

4. Dietary

If applicable, select any dietary requirements

Completion

We (parents/guardians) understand that the information requested on this form is required because the school has contractual and statutory duties towards your child. For more information about how the school will use this information, please see our pupil and parent privacy notice. Both of these documents are provided with the letter of offer and published on the School's website at www.mounthouse.org.uk/about-us/policies/. *

Yes

Prior to the commencement of the admissions process, we will contact you about any special arrangements your child may require.

Name of first signatory (as appears on registration form) *

First

Last

Name of second signatory (as appears on registration form) *

First

Last

Please put N/A if there is only one signatory

Date form completed *