ENROLMENT FORM
Please complete each question IN FULL
IMPORTANT:
The Department of Education & Skills operates an electronic database of post-primary school pupils called Post Primary Online Data (PPOD). The information requested below will be uploaded to PPOD and to our own school’s database Vsware.
SECTION 1: STUDENT DETAILS:
Year Group for which you are enrolling:___________________Male: □ Female: □
Student’s Name & Surname (as per Birth Certificate):______________________________
Student’s Christian Name known by (if different):_______________________________________
Date of Birth: ____________________________________________________
Address:________________________________________________________
________________________________________________________________
Student’s PPS Number: ____________________________________________
Nationality:______________________________________________________
Mother’s Maiden Name:____________________________________________
Is the pupil’s mother tongues (i.e. language spoken at home) English or Irish? Yes: □ No: □
Does this student have a Medical Card Yes: □ No: □
Brother(s) and/or sister(s) currently in this school (Name & Year Group) : _______________________
_________________________________________________________________________________________
SECTION 2: FAMILY DETAILS:
MOTHER/GUARDIAN FATHER/GUARDIAN
|
Christian Name
|
|
|
|
Surname
|
|
|
|
Occupation
|
|
|
|
Mobile Number
|
This number will be used for WebText
|
|
|
Landline Number (if available)
|
|
|
|
Work Number
|
|
|
|
Email Address
|
This will be used for some correspondance.
|
|
SECTION 3: ETHNIC & RELIGIOUS BACKGROUND:
The Information requested in this Section is OPTIONAL.
Do you consent to the information in relation to Religion & Cultural Background being uploaded to PPOD? Yes:□ No:□
Ethnic/cultural background:
To which ethnic or cultural background group does your child belong (please tick one)
(Categories based on the Census of Population)
White Irish Irish Traveller Roma Any other White Background Black or Black Irish - African Black or Black Irish - Any other Black Background
Asian or Asian Irish – Chinese Asian or Asian Irish - Any other Asian background
Other (inc. mixed background) No consent
Religion: What is your child’s religion?
Roman Catholic Church of Ireland (Anglican) Presbyterian
Methodist, Wesleyan Jewish Muslim (Islamic)
Orthodox (Greek, Coptic, Russian) Apostolic or Pentecostal Hindu
Buddhist Jehovah's Witness Lutheran
Atheist Baptist Agnostic
Christian Religion (not further defined) Protestant Evangelical
Other Religions No Religion No Consent
Section 3: EDUCATIONAL BACKGROUND
|
Primary School(s) Attended:
|
Year/s
|
|
20_ _ To _ _ _ _
|
|
20_ _ To _ _ _ _
|
|
|
Any Known Learning Difficulties? Yes q No q
If answer is ‘Yes’ please give details:
_________________________________________________________________________
Exemption from any subject? Yesq Noq
If answer is ‘Yes’ please give details:
|
Did Student Receive Special Help In Any Subject? Yes q No q
If answer is ‘Yes’ please give details:
|
Was an Educational / Psychological Assessment Ever Carried Out? Yesq Noq
If answer is ‘Yes’ please give details:
I give Mt St Michael permission to liaise with the primary school attended along with any other relevant agencies regarding the educational needs of my son/daughter.
Yes q___ No q
|
ACHIEVEMENTS
|
INTERESTS / HOBBIES
|
|
|
|
|
|
|
|
|
SECTION 4: HEALTH DETAILS
|
|
STATUS
(e.g Good)
|
Any Known Problems
|
ADDITIONAL DETAILS
|
General Health:
|
|
|
|
Eyesight:
|
|
|
|
Hearing:
|
|
|
|
Allergies:
|
|
|
|
Any existing conditions:
|
|
|
|
Able To Participate In Physical Education? Yes q No q
If answer is ‘No’ please give details:
|
Name: Address: Tel. No:
|
FAMILY DOCTOR: _____________________ ________________
|
|
I agree that in the case of an emergency, my son/daughter may be brought to the local doctor’s surgery or hospital if required. Yes q Noq
|
|
Has your son/daughter previously attended, or is he/she currently attending any agency which the school should be aware of? Yes q Noq
If Yes which agency? (such as NEPS, HSE, CAMHS, TUSLA, Other) _______________
|
SECTION 5: PARENT/GUARDIAN SIGNATURES:
Please be advised that by signing below you give consent for the above information to be stored in the school and shared with the Department of Education and Skills as requested.
I/We consent that my son/daughter may from time to time appear in educational, and/or promotional literature such as school noticeboards, newspapers, videos, newsletters, brochures, webpages, etc Yes No
I/We consent that my son/daughter may partake in tours and various other excursions involving travel outside the school grounds during the school year as organised by the school.
Yes No
I/We understand the procedures and policies of the school and with my son/daughter, I/we will endeavour to uphold and support them.
Signed (Parent/Guardian) _________________________________________
Signature of enrolling Teacher:____________________________ Date enrolled: _________________
It is the sole responsibility of Parents/Guardians to inform the school of any changes to the information provided on this form.
We look forward to working with you in the future. Thank You.