Parental Consent Make a Referral Parental ConsentPlease complete ALL sections before submitting. Pupil Details Name * First Name Last Name Date of birth * MM DD YYYY Address Address 1 Address 2 City State/Province Zip/Postal Code Country School (currently attending) * Year Group * Year 7 Year 8 Year 9 Year 10 Year 11 Parent/Guardian Information Name * The parent/guardian will be the primary emergency contact. First Name Last Name Relationship with Pupil * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone * (###) ### #### Emergency Contact Name The parent/guardian will be the primary emergency contact. If possible please provide an alternative. First Name Last Name Relationship with Pupil Address Address 1 Address 2 City State/Province Zip/Postal Code Country Email Phone (###) ### #### Medical Information Does your child have any medical conditions or disabilities? * Yes No Does your child require any medication during school hours? * Yes No Does your child have any allergies or dietry requirements? * Yes No Consent for Placement Please carefully read the following. * 1. Reason for Placement: o I understand the purpose and objectives of the alternative provision placement. o I acknowledge the expected outcomes and benefits for my child. 2. Details of the Placement: o I am aware of the name and location of EMS Tutors. o I understand the type of activities or educational focus provided. 3. Attendance and Reporting: o I acknowledge that my child’s attendance will be monitored and reported to their current school. 4. Data Sharing: o I consent to the sharing of relevant information, including medical and educational details, with the alternative provision provider to ensure appropriate support for my child. 5. Transportation Arrangements: o I confirm that any transportation arrangements for attending the alternative provision have been explained and agreed upon. I hereby consent to the above terms regarding my child's alternative provision placement. Declaration * By signing below, I confirm that the information provided is accurate and complete to the best of my knowledge. I understand the purpose of this placement and consent to my child attending the alternative provision setting, subject to the agreed arrangements. I acknowledge that I have read and understood the details outlined in this consent form. Name * First Name Last Name Date * MM DD YYYY Thank you!
