Initial Pupil Information Form (Please Complete All Sections Fully to Prevent Delays)

Initial Pupil Information Form (please complete all sections fully to prevent delays) M F Date Received Date sent Gender (office use only)

Name DOB Year Group

Parental Ethnicity Yes No Parent(s)/Carers Responsibility Religion

Address Yes No CAF

Yes No LAC

Telephone No(s) Yes No FSM

Yes No PSP

Yes No SA+ Statement Awaiting Health & SEN Safety Issues

… if yes please attach Risk Assessment

English English Present NC level Predicted Key Attendance Maths Stage Targets Maths Authorised Abs % this academic year Science Science Unauthorised Abs

CATS WRAT VRQ Verbal Non Verbal Quantitative Mean SAS Reading Age Spelling Age

School School Contact Position

BHLP (name)

Multi-Agency Working and Supporting Documents Agency / Service Name of professional Contact details Documents / reports Attached involved

Print Sign Date Request submitted by: Headteacher

Why are you referring this pupil to CTAPS?

What measures have the . school already taken to support this pupil? .

How successful have they been? .

How many days of Please note that the referring school may be required to exclusion has this pupil provide work for independent study in Maths, English and had this year? Science for this pupil to complete in Centre Yes No Have you informed the Yes No If yes have parents agreed to parents / carers that you this placement? are making this referral?

Yes No Have the pupils’ needs been discussed with a PRS Manager?

Yes No Are there any safeguarding issues that the PRS need be aware of? If yes please specify separately Please add additional information here, such as: . college placements . work experience . exam requirements etc

Data Protection Act. This information is being collected for the purpose of determining the educational needs of the named pupil, but may also be shared with other relevant professionals to inform their work. The information collected may also be used for the wider purpose of providing anonymised statistical data to assist with monitoring of provision and/or determining areas of need in order to target future resources. For further information please contact Michael Buist, Headteacher on 01242 581519.

Please return this form to: Michael Buist, Headteacher Cheltenham & Tewkesbury APS, St Georges Centre, Alstone Lane, Cheltenham, Gloucestershire GL51 8HH [email protected] (E-mail)  01242 581519