1st Language: Interpreter required: YES NO Does this person have parental responsibility: YES NO (if NO complete below) – Name of person with Parental Responsibility and contact details: Other significant members of the family: HEALTH Is the student taking any medication or have any allergies? YES NO Does the learner have any health/support needs, including mental, emotional and physical? YES NO Is the learner currently working with any other agencies to access support with any health issues? YES NO SPECIAL NEEDS INFORMATION Does the learner have any disabilities? YES NO Does the learner have any special needs? YES NO If yes, at what stage are they? (please tick) School Action School Action + Statement/EHCP Is there an ILP/PEP in place? YES NO Additional information attached (if required) YES NO SAFEGUARDING Is the learner currently working with any other agencies to access support with any safeguarding YES NO Issues? Does the learner have any caring responsibilities? YES NO Does the learner feel safe from harm? YES NO AGENCY INVOLVEMENT: please provide contact details including lead professional, actions following agency involvement and outcomes Education psychologist Contact: Actions: Outcomes: Attendance and Pupil Support Service Contact: Actions: Outcomes: Family Support and Child protection Services Contact: (Social Worker) Actions: Outcomes: Mental Health Services CAMHS CHEWS Contact: Actions: Outcomes: Health Contact: Actions: Outcomes: YOT Contact: Actions: Outcomes: Other please specify: Contact: Actions: Outcomes: GENERAL LEARNER INFORMATION Please use this box to include any additional information regarding anything that could prohibit the young person from achieving/engaging with Learning? (eg travel, caring, responsibilities, previous negative experiences, relationship to parents etc.)
1st Language: Interpreter required: YES NO Does this person have parental responsibility: YES NO (if NO – complete below) Name of person with Parental Responsibility and contact details: Other significant members of the family: HEALTH Is the student taking any medication or have any allergies? YES NO Does the learner have any health/support needs, including mental, emotional and physical? YES NO Is the learner currently working with any other agencies to access support with any health issues? YES NO SPECIAL NEEDS INFORMATION Does the learner have any disabilities? YES NO Does the learner have any special needs? YES NO If yes, at what stage are they? (please tick) School Action School Action + Statement/EHCP Is there an ILP/PEP in place? YES NO Additional information attached (if required) YES NO SAFEGUARDING Is the learner currently working with any other agencies to access support with any safeguarding Issues? YES NO Does the learner have any caring responsibilities? YES NO Does the learner feel safe from harm? YES NO AGENCY INVOLVEMENT: please provide contact details including lead professional, actions following agency involvement and outcomes Education psychologist Actions: Contact: Outcomes: Attendance and Pupil Support Service Actions: Contact: Outcomes: Family Support and Child protection Services (Social Worker) Actions: Contact: Outcomes: Mental Health Services CAMHS CHEWS Actions: Contact: Outcomes: Health Actions: Contact: Outcomes: YOT Actions: Contact: Outcomes: Other please specify: Actions: Contact: Outcomes: GENERAL LEARNER INFORMATION Please use this box to include any additional information regarding anything that could prohibit the young person from achieving/engaging with Learning? (eg travel, caring, responsibilities, previous negative experiences, relationship to parents etc.)
Brian-Jackson-College-Independent-Inclusion-for-KS4-application-form.docx