To Be Completed at Time of Permanent Exclusion

Special Educational Needs and Inclusion Services

NOTIFICATION OF PERMANENT EXCLUSION To be completed at time of permanent exclusion

Name of School …………………………………………….………...... ……

Contact Person ………………………………………………………………

PUPIL DETAILS

SURNAME …...... ………………………………………………………………………………

FIRST NAME ………………...... ………..…....…MIDDLE NAME ……...... ………….……………

ADDRESS ……………………………………………………………………………………………………………………………

TELEPHONE NO (s) ……......

UPN ………………………………………….. GENDER Male Female

DATE OF BIRTH …….…/…….…/………. NCY GROUP ……...... KEY STAGE ………… IS THE PUPIL PEP attached YES NO LOOKED AFTER? YES NO HAVE THERE BEEN LEAD CONTACT ANY CAF / EHA CONTACT DETAILS MEETINGS CALLED? YES NO PERSON IS THE PUPIL ON A LEAD CONTACT CHILD PROTECTION CONTACT DETAILS PLAN? YES NO PERSON DOES THE PUPIL HAVE LEAD LAST REVIEW AN IEP / PSP? CONTACT DATE IEP YES NO PERSON Please attach last available copy of PSP YES NO IEP IEP IEP /PSP PSP PSP

HAS THE PUPIL Name of school attended ...... BEEN THE SUBJECT Last review date ……….…...... Date of breakdown …….....…….. OF A MANAGED YES NO MOVE? Reason for breakdown ......

Details: DOES THE PUPIL HAVE SEN? (Include details of Statement / EHCP)

YES NO

IS THE PUPIL IN RECEIPT OF FREE SCHOOL MEALS? YES NO

DOES THE PUPIL ATTRACT PUPIL PREMIUM?

YES NO Special Educational Needs and Inclusion Services

ETHNICITY (Please tick one box) Code Code  British WBRI  Indian AIND  Irish WIRI  Pakistani APKN  Traveller - Irish Heritage WIRT  Bangladeshi ABAN  Gypsy/Roma WROM  Any Other Asian Background BOTH  Any Other White Background WOTH  Chinese CHNE  White/Black Caribbean MWBC  Any Other Ethnic Group OOTH  White/Black African MWBA  Refused REFU  White/Asian MWAS  Any Other Mixed Background MOTH  Traveller TRV  Black Caribbean BCRB  Asylum Seeker ASY  Black African BAFR  Any Other Black Background BOTH

EXCLUSION REASON (Please tick one box)

PP Physical assault against a pupil SM Sexual misconduct PAPP Physical assault against an adult DA Drug and alcohol related VP Verbal abuse/threatening behaviour against a pupil DM Damage VA Verbal abuse/threatening behaviour against an adult TH Theft BU Bullying DB Persistent Disruptive Behaviour RA Racist abuse

Have the Police been informed/involved in connection with this exclusion? Yes No

FIRST DAY OUT OF SCHOOL ____/____/____ (Effective date of exclusion)

ATTENDANCE DATA Over the last/current Academic Year ...... %

PARENT/GUARDIAN/CARER DETAILS

TITLE MR MRS MS MISS

SURNAME ......

FIRST NAMES ......

ADDRESS ......

(if different from above) ...... POST CODE ......

TELEPHONE/MOBILE ......

RELATIONSHIP TO PUPIL

Parent Carer Guardian (e.g. grandparents)

Details of any other person with Parental Responsibility: Special Educational Needs and Inclusion Services

AGENCIES INVOLVED

AGENCY Yes No Contact Person/and Outcomes

Local Support Team

Child in Need/ Child Protection

Other: Please Define

STRATEGIES

Support from Tutor YES NO Placement @ LSU YES NO

Learning Mentor YES NO Reduced Timetable YES NO

Peer Mentor YES NO Managed Move YES NO

School Report YES NO Alternative Education YES NO

PUPIL ACADEMIC PROFILE

KS2 SATs Predicted grades Actual results KS4 GCSEs Predicted grades

English English Maths Maths Science Science KS4 additional information

Subject Exam Board Course work completed to date (please forward) Predicted grades

Name of Headteacher...... Date......

Please complete and return the form to: [email protected]