In-Year Common Preference Form (ICPF)

This form must be used when making an In-Year application for a place in an Academy within The GORSE Academies Trust

Should you as a family require professional support in completing this form please contact Andrew Elliott on 0113 2898990

Specific support is available for any family whose first language is not English

* Please see the guidance notes at the end of this form

1: Child’s details
Child’s Full Name:
Any Other Surnames Used:
Date of Birth:
Male/Female:
Current Year Group:
Home Address: (This is the place where the child normally lives)
Postcode:
2: Parent’s/Carer’s details
Please print your name:
Your relationship to the child:
Who has parental responsibility for the child?
Phone number(s):
Email:
3: Reason for changing school/academy
□ Moving from one area of Leeds to a different area of Leeds
□ Moved to Leeds from another area of the UK
□ Moved to Leeds from another country
□ Not moving, but want to change schools
4: School/Academy requested
Please list which schools/academies you would like to apply for in order of preference:
1)
2)
3)
4)
5)
5. Siblings
* Please give details of the child’s siblings
Sibling’s full name / Sibling’s date of birth
dd/mm/yyyy / Sibling’s school
6. If you are moving house - You must attach some documentary evidence of your move – a council tax bill for your new property and an exit utility bill from your previous address. The Trust reserves the right to visit the child’s home.
1) Old address:
Postcode:
2) New address:
Postcode:
Date of move:
PLEASE NOTE: Your address can only be updated once sufficient evidence has been provided.
7. If you have moved to the UK
When did you arrive in the UK?
DD / MM / YY
When did the child arrive?
DD / MM / YY
Country of origin:
What is the first language of the child?
Does your child speak English? Yes No Some
Please attach photocopies of the following documents with your completed application form:
  • your passport and the child’s passport;
  • if you are an asylum seeker or refugee the Home Office document confirming your status
  • we need to see proof of date of birth e.g. passport, birth certificate or Home Office document
When did you arrive in Leeds?
DD / MM / YY
8. Why do you want the child to move school/academy? Please give as much information as possible to support your request. (Please attach additional sheets if necessary.)
9.Current school/academy:
Name of school/academy:
Town of school/academy:
Date of leaving:
Reason for leaving:
Please name any other schools/academies which the child has attended in the last 5 years (please attach additional sheets if necessary).
Name of school/academy:
Town of school/academy:
Date of leaving:
Reason for leaving:
Name of school/academy:
Town of school/academy:
Date of leaving:
Reason for leaving:
Name of school/academy:
Town of school/academy:
Date of leaving:
Reason for leaving:
Name of school/academy:
Town of school/academy:
Date of leaving:
Reason for leaving:
Name of school/academy:
Town of school/academy:
Date of leaving:
Reason for leaving:
Name of school/academy:
Town of school/academy:
Date of leaving:
Reason for leaving:
10. Past behaviour of the child:
The Trust owes a duty of care to all of its students, staff and visitors. To ensure that we are able to fulfil this legal obligation we need to be sure that we have knowledge of any instances when the child’s behaviour has:
• led to the involvement of any outside agency, and/or
• caused any problems at a school/academy
Important note: If relevant information regarding the child’s past behaviour is not disclosed and harm or damage is suffered as a result, the Trust may seek legal redress from any party which wilfully chose not to disclose such information.

11. Additional information about your child

THIS SECTION MUST BE COMPLETED – AT LEAST ONE BOX MUST BE TICKED

* *Please indicate whether the child has/is any of the following. Please tick all that apply:

□ Education and Health Care Plan (formally called a Statement of Special Education Needs)

□ Special educational needs requiring specific support, but without a Statement (please state) ______

□ Disability/serious medical condition, but without a statement (please state) ______

□ On School Support (which was previously called School Action Plus)

□ Looked After Child

□ Previously Looked After Child

□ Homeless

□ Had fixed-term exclusion (s) (please state) ______

□ Young Carer

□ Gypsy, Roma or Traveller Child

□ Asylum Seeker or Refugee Child

□ Less than 85% attendance at current school

□ Behavioural issues

□ At risk of permanent exclusion

□ Out of education for more than two months

□ Known to the police, youth offending service ,the courts, CAHMS, Signpost or another support agency

□ Known to Social Care (name of social worker) ______

□ Returning from the criminal justice system or a Pupil Referral Unit

□ Been permanently excluded

□ Returning from Elective Home Education

□ None of the above

12. Head teacher’s declaration that all of the information contained in this form is accurate

Signature of current Head teacher: ______

Please print name: ______

Date: ______

Additional Information attached Yes/No

Current School/Academy Stamp

13. Parent’s/Carer’s declaration

Data Protection Act 1998
Under the terms of the Data Protection Act 1998 we must tell you of the following:
By signing this form you are giving your consent for The GORSE Academies Trust to use your data. The Trust may also share the information you provide with relevant professionals for the purposes of offering your child a place at an academy.
Declaration
“I consent to The GORSE Academies Trust processing the information detailed in this form. I understand that this will be used by the Trust for its administration purposes and my consent is based upon The GORSE Academies Trust complying with the Data Protection Act 1998”.

By signing below, I confirm that:

• I am the parent/carer/legal guardian of the child and I have parental responsibility for them.

• The information I have provided on this form is true.

• I understand that any academy place offered on the basis of fraudulent or intentionally misleading information will be withdrawn.

• I consent to the information provided on this form being shared with appropriate agencies.

Signature of parent/carer: ______

Date: ______

Additional Information attached Yes/No

*Guidance for filling in this form

Section 5: Siblings

Siblings refers to full brother or sister, half brother or sister, adopted brother or sister, step brother or sister, foster brother or sister. The definition does not include cousins or other family members merely sharing a house. For these purposes, brothers and sisters must be living at the same address as your child.

Section 11: Additional Information

If any of these categories do apply to your child, telling us about it will help the Academy to process your application for a change of school. These categories form part of the local Fair Access Protocol. More information can be found at www.leeds.gov.uk or in the ‘Starting Primary School’ and ‘Starting Secondary School’ booklets.

Section 12: Current school information

We need your child’s current Head teacher to sign in this section for us to process your application without delay. The form must be signed and stamped.

Please return this form to the academy.