Name of child Date of Birth Current pre-school/nursery Primary school that your child will attend Name of Parent/Guardian Address Telephone number E-mail address Please indicate the position of other children within your family Child one Child two Child three Child four Has your child had any involvement with any of the following professionals? Has your child had any involvement with any of the following professionals? YesNo Speech and Language Speech and Language - Yes Speech and Language - No Health Health - Yes Health - No Educational Psychologist Educational Psychologist - Yes Educational Psychologist - No Social Work Social Work - Yes Social Work - No Have you read our parental leaflet "Early Entry to Primary School"? - None -YesNo Have you had the opportunity to discuss your child with pre-five staff and/or the Head Teacher of the school? - None -YesNo Have you received a copy of the profile report from the nursery/pre-school? - None -YesNo Please give reasons for your application Try to comment as fully as possible on your child's needs. Declaration by Parent/Guardian After full consideration, I wish to formally apply for early entry to Primary school for my child. I accept that this will involve a formal assessment by an Early Years lead and/or a designated staff member from the receiving school. Name of Parent/Guardian The information you supply on this form will be used for the purpose for which you have provided it, and appropriate measures are in place to protect your personal data. A full privacy notice, which provides information about your rights under current data protection legislation and details about what will happen to your personal data can be found here: Privacy Notice - Early entry to primary school Leave this field blank