Christian 3 C of E Catholic Buddhist Hindu Muslim Your Religion (state): (Please tick) Other religion (state) Sikh Jewish Jehovah’s Witness No religion Your Child’s Ethnic White (UK) White (Irish) White (Other) Origin (Please tick one) Black Caribbean / British Indian / British Indian Arabic Other Mixed Background Pakistani / Black African / British Chinese Other Asian Background British Pakistani Bangladeshi / Other Black Background Other Ethnic Category Refused British Bangladeshi Does your child need an Interpreter? What is your child’s main spoken language? Yes No Does your child need help with mobility/hearing/speaking? (tick all that apply) Wheelchair Walking aid Hearing aid British sign language Makaton sign (BSL) language Lip reading: Large print: Braille Other. Please state: Is your child Homeless A Refugee An Asylum Seeker currently? Is your child housebound? Yes No Comments: 4 Medical background Are there any serious diseases that affect your child’s parents, brothers or sisters? Tick all that apply and state family member: Diabetes Asthma Thyroid disorder Stroke COPD Who: Who: Who: Who: Who: Heart Attack under age of Cancer (Specify type) High Blood pressure Any other important family 60 illness. Please state: Who: Who: Who: Who: Please state any allergies and sensitivities that your child has to medicines, food & dressings: Please state any mental disabilities your child has: Does your child have any problems taking Yes No If yes please give details, e.g. swallowing medicines?
3 Your Religion (Please tick) C of E Catholic Christian (state): Buddhist Hindu Muslim Sikh Jewish Jehovah’s Witness No religion Other religion (state) Your Child’s Ethnic Origin (Please tick one) White (UK) White (Irish) White (Other) Black Caribbean / British Indian / British Indian Arabic Other Mixed Background Black African / British Pakistani / British Pakistani Chinese Other Asian Background Other Black Background Bangladeshi / British Bangladeshi Other Ethnic Category Refused What is your child’s main spoken language? Does your child need an Interpreter? Yes No Does your child need help with mobility/hearing/speaking? (tick all that apply) Wheelchair Walking aid Hearing aid British sign language (BSL) Makaton sign language Lip reading: Large print: Braille Other. Please state: Is your child currently? Homeless A Refugee An Asylum Seeker Is your child housebound? Yes No Comments: 4 Medical background Are there any serious diseases that affect your child’s parents, brothers or sisters? Tick all that apply and state family member: Diabetes Who: Asthma Who: Thyroid disorder Who: Stroke Who: COPD Who: Heart Attack under age of 60 Who: Cancer (Specify type) Who: High Blood pressure Who: Any other important family illness. Please state: Who: Please state any allergies and sensitivities that your child has to medicines, food & dressings: Please state any mental disabilities your child has: Does your child have any problems taking medicines? Yes No If yes please give details, e.g. swallowing