Breda Academy Student Registration Form

Please ensure you complete every section of this form:

This form should be completed and signed by individual(s) with parental responsibility for the named child
The information given on this form is confidential; it is treated as such and will not be released or discussed with any unauthorised individual.
Please complete all sections, including giving ‘no’ or N/A responses where appropriate.
It is the responsibility of the individual(s) with parental responsibility for the named child to keep school informed of any changes in personal details, address, phone number or email. This has to be done in writing or by e mail.

Section 1

1. Surname (as on birth certificate): *

2. Middle Name(s) (as on birth certificate) *

3. Forename (as on birth certificate) *

4. Preferred Forename: *

5. Preferred Surname: *

6. Gender *

Male

Female

7. Date of birth *

YYYY

Section 2

8. Home Address *

9. Postcode *

Siblings currently at Breda Academy:

10. Name:

11. Form

12. Are there any court orders which relate to the child eg, custody, contact, or residence orders under the Children NI Order 1995? If YES, please identify them and copies MUST be provided to the school.

Yes

Please give details of all persons who have parental responsibility and someone else who can be contacted if your child is unwell or in an emergency. Please number them in the order in which you wish them to be contacted.

13. Mother / Carer - Emergency Contact 1 / 2 / 3? *

14. Parental Responsibility? *

Yes

15. Full Name (Mrs, Mr, Dr, Rev, Miss, Mr) *

16. Mobile number *

17. Email Address *

18. Home address (if different to pupil's) - If not applicable please enter 'n/a' *

19. Telephone Number at work (+ extension)

20. Father / Carer - Emergency Contact 1 / 2 / 3?

21. Parental Responsibility?

Yes

22. Full Name (Mrs, Mr, Dr, Rev, Miss, Mr)

23. Mobile Number

24. Email Address

25. Home Address (if different from the pupil's)

26. Telephone Number at work (+ extension)

27. Contact - Emergency Contact 1 / 2 / 3?

28. Relationship to pupil

29. Full Name (Mrs, Mr, Dr, Rev, Miss, Mr)

30. Contact number

Section 3

35. Medical practice *

36. Medical conditions (Please contact the school if necessary to provide more detailed information)

37. Is this required during the school day? We recommend that where possible medication is not administered during the school day. Please give details:

Self administration of prescription of proprietary medicines is prohibited.
This must only be carried out under the supervision of a School Nurse, who will arrange for medicine to be stored and dispensed in accordance with written parental instructions. Please write to the Vice Principal.

Parents must supply any prescribed medication in the original packaging with pharmacy typed instructions attached.

It is the responsibility of parents to ensure all medications stored by the school are up to date.

Section 6

38. Does your child have a disability? *

Yes

39. If yes, please give details:

40. Does your child have a Special Education Need? *

Yes

Not Applicable

If YES, you must include documentary evidence of a formal diagnosis by HSC Trust or EA Psychologist to the school.

41. If your child is currently on a school's SEN register, please select which stage: *

N/A

42. Date of statement (Stage 3 only):

YYYY

Please send into the school all relevant documentation to evidence this need, this may include any of the following documentation:

Last annual review of statement
EA psychologist report
HSC Trust letter indicating formal diagnosis
CAMHS letter of involvement
Occupational Therapy reports etc

Section 7

43. Primary / Secondary school attended name: *

44. Date attended from *

YYYY

45. Date attended to *

YYYY

46. Is your child entitled to free school meals? It is your responsibility to apply through the EA website. *

Yes

47. Is your child the eldest child or the first child in your family to transfer to a mainstream post primary school?

Yes

48.

School Communications - School Gateway App

All information relating to the School Gateway App

Please could you download the gateway app to your phone
The set up process is simple and will take no more than a couple of minutes:

1 - Search for "School Gateway" in the Apple App Store/Google Play on your phone, go to www.schoolgateway.com/apple (Apple) or www.schoolgateway.com/android (Android)
2 - Install the app and if you are asked then say yes to "Allow Push Notifications"
3 - When you launch School Gateway for the first time, please select 'New User; and enter the email address and mobile telephone number you have registered with the school.
4 - The system will send a PIN code to your phone; please enter this PIN code and the app will be activated for you. As soon as you've got the system set up, all of the text messages we send you will appear in the app' you'll receive notifications/alerts as normal.

I have read and understood the requirements of the School Gateway Acceptable Use policy and agree to abide by the conditions outlined in the policy. Please write your name below if you accept and provide your email address.

Please tick the boxes to acknowledge that you and your child have agreed to the following Breda Academy policies:

49. Mobile Phone Policy / (Pg 28 CP Policy) *

50. Internet Policy: *

51. Photograph Permission *

52. School Gateway app *

53. Email address *

54.

I accept all school Policies and Procedures including, uniform policy and child protection policy (all available on website).

Signature of Parent/Carer:

PLEASE ENSURE ALL SECTIONS ARE COMPLETED AND SIGNED

Website

Address

Breda Academy,
Newtownbreda Road,
Belfast,
County Antrim,
Northern Ireland,
BT8 6PY

Telephone

028 9064 5374

contact@breda.academy

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