ANNEX B
This information on this form is processed electronically for administration purposes and is subject to the terms of the Data Protection Act 1984
Pupil's Forename's
These are names, which will appear on public examination certificates
Email Address
(* please use your valid e-mail address -
without this, the form will not be transmitted to us)
 *
Pupil's Surname
Pupil's Date of Birth
day month year
Sex
male female
 
Brothers and Sisters at Queen Ethelburga's (if any)
 Yes No
Name(s)
Parents/Guardians living at pupil's home address
Relationship to pupil
Title
 Mr    Mrs   Miss   Ms
Forename's
Surname
Can be contacted in an emergency during the day
 Yes No
If yes give whereabouts (eg at home or name of workplace)
Daytime Telephone Number
Pupil's Home Address
Post Code
Home Telephone Number

Letters will be addressed to the parents/guardians named above using the pupil's address. If this is not appropriate, please place alternative address here
Other emergency contact
(excluding parents/guardians)
GIve names, daytime telephone number & relationship to pupil
Pupil's previous School
Medical Details
Home Doctors Name
(UK resident only)
Tel No:
Address
Parents may convey relevant medical information here or under separate cover to the school. The information is processed electronically but in a coded form to enable staff to respond to pupils' needs
Additional Parental Contact For the purposes of the school records, a pupil's parent is defined as his/her natural parent and any other person who is his/her guardian, who has custody of, or who is likely to maintain him/her. Please add below anyone who comes into this category but who is not included earlier.
Relationship to pupil
Title
 Mr    Mrs   Miss   Ms
Forenames
Surnames
Address
Postcode
Mobile Tel No.
Home Telephone No.
Work Telephone No.
Details of Guardian in UK acting for parents and being responsible fo student during half terms (If not detailed in the box above)
Title
 Mr    Mrs   Miss   Ms
Forenames
Surnames
Date of Birth
Address
Postcode
Mobile Tel No.
Home Telephone No.
Work Telephone No.
Relationship to student
Occupation
Request for Guardian in UK
Please provide me with details of guardianship services offered by the college
Yes   No   
I declare the information on this form to be correct to the best of my knowledge
Name