<p> Special Educational Needs and Inclusion Services </p><p>NOTIFICATION OF PERMANENT EXCLUSION To be completed at time of permanent exclusion</p><p>Name of School …………………………………………….………...... ……</p><p>Contact Person ………………………………………………………………</p><p>PUPIL DETAILS</p><p>SURNAME …...... ……………………………………………………………………………… </p><p>FIRST NAME ………………...... ………..…....…MIDDLE NAME ……...... ………….……………</p><p>ADDRESS ……………………………………………………………………………………………………………………………</p><p>TELEPHONE NO (s) ……...... </p><p>UPN ………………………………………….. GENDER Male Female</p><p>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</p><p>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 ...... </p><p>Details: DOES THE PUPIL HAVE SEN? (Include details of Statement / EHCP)</p><p>YES NO </p><p>IS THE PUPIL IN RECEIPT OF FREE SCHOOL MEALS? YES NO </p><p>DOES THE PUPIL ATTRACT PUPIL PREMIUM?</p><p>YES NO Special Educational Needs and Inclusion Services </p><p>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</p><p>EXCLUSION REASON (Please tick one box) </p><p>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</p><p>Have the Police been informed/involved in connection with this exclusion? Yes No </p><p>FIRST DAY OUT OF SCHOOL ____/____/____ (Effective date of exclusion) </p><p>ATTENDANCE DATA Over the last/current Academic Year ...... %</p><p>PARENT/GUARDIAN/CARER DETAILS </p><p>TITLE MR MRS MS MISS</p><p>SURNAME ...... </p><p>FIRST NAMES ...... </p><p>ADDRESS ...... </p><p>(if different from above) ...... POST CODE ...... </p><p>TELEPHONE/MOBILE ...... </p><p>RELATIONSHIP TO PUPIL </p><p>Parent Carer Guardian (e.g. grandparents) </p><p>Details of any other person with Parental Responsibility: Special Educational Needs and Inclusion Services </p><p>AGENCIES INVOLVED</p><p>AGENCY Yes No Contact Person/and Outcomes </p><p>Local Support Team </p><p>Child in Need/ Child Protection </p><p>CAMHS</p><p>YOT</p><p>Other: Please Define </p><p>STRATEGIES </p><p>Support from Tutor YES NO Placement @ LSU YES NO</p><p>Learning Mentor YES NO Reduced Timetable YES NO</p><p>Peer Mentor YES NO Managed Move YES NO</p><p>School Report YES NO Alternative Education YES NO</p><p>PUPIL ACADEMIC PROFILE</p><p>KS2 SATs Predicted grades Actual results KS4 GCSEs Predicted grades </p><p>English English Maths Maths Science Science KS4 additional information</p><p>Subject Exam Board Course work completed to date (please forward) Predicted grades</p><p>Name of Headteacher...... Date...... </p><p>Please complete and return the form to: [email protected] </p>