Please return WITH YOUR ECHP to: Education Liaison Service, St Piers School & College, St Piers Lane, Lingfield, Surrey RH7 6PW. Email: Tel: 01342 832243 Application Form Applicant’s full name Applicant’s address Applicant’s postcode Local authority Date of birth Gender (male/female) Nationality Religion Home language Applicant’s ethnic origin Black or Black White Mixed Asian or Asian Other British British British White/Black Indian Caribbean Chinese Irish Caribbean Pakistani African Other Other White/Black Bangladeshi Other Please specify: Please specify: African Other Please specify: Please specify: Other Please specify: Placement commencing Placement type 2018 2019 Day Weekly (Mon-Thur boarding) Termly 2020 2021 48 52 weeks PARENTAL RESPONSIBILITY: In accordance with The Children Act 1989, Please give full details below of ALL persons with parental responsibility and to whom correspondence, reports invitations etc. should be sent. Have there been any safeguarding or child/adult protection concerns related to this child/young person? Yes No Is the young person looked after by If is it: ‘Yes’ Involuntarily through a Care Order local authority? Voluntarily under section 20 or 85 Yes No Parent/Carer 1 Name
Please return WITH YOUR ECHP to: Education Liaison Service, St Piers School & College, St Piers Lane, Lingfield, Surrey RH7 6PW. Email: Tel: 01342 832243 Application Form Applicant’s full name Applicant’s address Applicant’s postcode Local authority Date of birth Gender (male/female) Nationality Religion Home language Applicant’s ethnic origin White Mixed Asian or Asian British Black or Black British Other British Irish Other Please specify: White/Black Caribbean White/Black African Other Please specify: Indian Pakistani Bangladeshi Other Please specify: Caribbean African Other Please specify: Chinese Other Please specify: Placement commencing 2018 2019 2020 2021 Placement type Day Weekly (Mon-Thur boarding) Termly 48 52 weeks PARENTAL RESPONSIBILITY: In accordance with The Children Act 1989, Please give full details below of ALL persons with parental responsibility and to whom correspondence, reports invitations etc. should be sent. Have there been any safeguarding or child/adult protection concerns related to this child/young person? Yes No Is the young person looked after by local authority? Yes No If ‘Yes’ is it: Involuntarily through a Care Order Voluntarily under section 20 or 85 Parent/Carer 1 Name
St-Piers-Application-Form-July-2017.docx