Knutton St Mary's C of E Academy

Knutton St Mary’s C of E Academy

Together we succeed and shine … ‘We shine like bright stars in the sky’ Philippians 2:15

Application for Admission to Nursery Aged Settings Before completing this form, you should read the Nursery Admissions Policy and Guidance provided on our website at www.ksmacademy.comk

Please complete your application electronically* and email to: [email protected] Alternatively, you can submit your completed handwritten form to the academy office. CHILD’S DETAILS

Child’s Legal Surname: Date of Birth:

Child’s Legal First Name: Male:  Female: 

Full Postal Address: (including postcode)

NB: it is your responsibility to advise us immediately if these details change.

Present/previous Nursery provider

Is your child a twin of triplet, etc (one of multiple birth)? Yes No

If yes, please provide the names of related applications:

Is this child in the care of a local authority? Yes No

Has the child previously been in the care of a local authority but has since been adopted (or become subject to a residence order or special guardianship order since being in public care?) Yes No

If ‘Yes’ to either of the above, please provide Social Worker and Local Authority contact details in the box below:

From a returning Service/Crown Servant family? Yes No

Does this child have a statutory statement of educational need or Education, Health and Care Plan (EHCP)? Yes No

Knutton St Mary’s C of E Academy, Church Lane, Knutton, Newcastle-under-Lyme, Staffordshire, ST5 6EB Principal: Mrs Anna Wheaverel: 01782 568680 email: [email protected] Web: www.ksmacademy.com Twitter: @KSMacademy Knutton St Mary’s C of E Academy is operated by St. Bart’s Multi Academy Trust which is a charitable company limited of guarantee and registered in England and Wales with company number 8735454. The registered office is at Belgrave St Bartholomew’s Academy, Sussex Place, Stoke on Trent, Staffordshire. ST3 4TP. 1 of 3

Knutton St Mary’s C of E Academy

Together we succeed and shine … ‘We shine like bright stars in the sky’ Philippians 2:15 DETAILS OF OLDER SIBLINGS ATTENDING KNUTTON ST MARY’S C OF E ACADEMY

Name of Sibling: Name of Sibling:

Date of Birth: Date of Birth:

School attending: School attending:

Current Year Group: Current Year Group:

DETAILS OF PERSON COMPLETING THIS FORM

Title

Surname:

First Name:

Relationship to Child:

Contact Number:

Email Address:

If you are caring for someone else’s child for more than 28 days and are not an immediate relative, you may be privately fostering and it is a legal requirement that you contact the local authority on 0800 1313126. Further information is available at www.staffordshire.gov.uk.

Knutton St Mary’s C of E Academy

Together we succeed and shine … ‘We shine like bright stars in the sky’ Philippians 2:15

ADDITIONAL INFORMATION TO SUPPORT YOUR APPLICATION

DECLARATION AND SIGNATURE OF APPLICANT The information provided on this application form will be used to ensure that the school’s records are correct. The full Privacy Notice can be found at www.ksmacademy.com I certify that the information I have provided is true to the best of my knowledge, and understand that any false or deliberately misleading information provided on this form and/or supporting papers may render this application invalid and could lead to the withdrawal of an offer of a school place for my child.

Name:

Signature: Date: