Student application form

Child's details

• First name * 
• Last name * 
• Date of birth * 
• Gender * Male  Female
• Year group * 
• Present school attending * 

• House/Flat Number * 
• Street Name * 
• City * 
• County * 
• Postcode * 

Parents'/ Carers' details

• Title * 
• First name * 
• Last name * 
• Relationship * 
• Home phone * 
• Mobile * 
• Email * 

• Title * 
• First name * 
• Last name * 
• Relationship * 
• Home phone * 
• Mobile * 
• Email * 

Children in Care (looked after children)

• Is this child looked after by a Local Authority? * Yes  No

• If yes, which Local Authority?
• Name of Social Worker

Reason for our application

• Please state your reason(s) for applying to the Hackney UTC:

Further information

• Does your child have a Statement of Special Educational Needs? * Yes  No
• Please note: This form should not be completed for a child who has a Statement of Special Educational Need – you can contact The Special Needs and Assessment Team for advice about applying to Hackney UTC.
• If not, is the pupil on School action?  Or School Action Plus?
• Is this for Medical/Physical Sensory BESD SLCD SLD MLD ASD PMLD
• other
• Specify here if it is for something not listed in the previous list.
• National Curriculum levels or Teacher's Assessment
  Maths
• English
• Science
• English as an additional language
• Home Language * 
• Has your child been permanently excluded from one or more schools? * Yes  No
• If yes, please provide name of school(s) and date(s) of exclusion
• Has your child been excluded for any fixed periods during the last two years? * Yes  No
• If yes, please provide date(s), duration and name of school
• Has your child been referred to or involved with any other support agencies such as School Attendance Service or Inclusion Team? * Yes  No
• If yes, (please provide details below)

Declaration

• I confirm that I wish to apply for a place for my child at Hackney UTC. I understand that a place may be withdrawn if it is offered because of fraudulent or misleading information I understand that the information I give on this form will be shared with schools and other Local Authorities for school admissions purposes I certify that I am the person with parental responsibility for the child named above and that the information given is true to the best of my knowledge and belief

* denotes a mandatory field