Information Record
Child’s surname...............................................
Child’s forename(s)...........................................
Date of Birth.......................................
Sex(M/F)...............
Child’s Address.......................................................................................................................
Post Code........................
Home telephone number...............................
Father’s work address.................................................................................................................
Phone number........................................
Mother’s work address.................................................................................................................
Phone number........................................
Please indicate the name, relationship, address and phone number of up to two people who may be contacted in an emergency. (Relatives, neighbours etc.)
Name 	 	Relationship 	Address 	 	 	Phone
1 ...........................................................................
2 ...........................................................................
Doctor’s name and surgery....................................................
Phone number.......................................
Please indicate below any medications, allergies, conditions and known disorders etc.
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Father’s name & address (if different from child’s)
...................................................................
...................................................................
Mother’s name & address (if different from child’s)
...................................................................
...................................................................
Who has Parental Responsibility for this child?
BOTH NATURAL PARENTS/OTHER (Please state)
...................................................................
Has an Order under the Children Act been made?  YES/NO
(If “YES” then please give details overleaf)
If there is any further information you feel we should know, (e.g. family circumstances) please indicate below.
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Signed (Father/Guardian)........................Date...............
Signed (Mother/Guardian)........................Date...............
PTO
Orders made under the Children Act 1989.
If such an order has been made in respect of this child, please complete the details below as they affect the school appropriate to the type of order made.
Date of order.................................................
Supervision Order
................................................................................ 
................................................................................ 
Care Order
................................................................................ 
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“Section 8” Orders
Residence Order
Name of Person(s) with Parental Responsibility........................................
................................................................................ 
Address given in order................................................................
................................................................................ 
Other details.........................................................................
................................................................................ 
Contact Order
Name of Person Allowed Contact........................................................
Does the Order allow contact at school?   YES/NO
Other details.........................................................................
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Prohibited Steps Order
Please give details of any prohibition affecting the school...........................
................................................................................ 
................................................................................ 
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Specific Issue Order
Please give details of any Specific Issue affecting  school...........................
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Signed (Father/Guardian)........................Date...............
Signed (Mother/Guardian)........................Date...............