Elective Home Education - Safeguarding Pupil Form

Legal Surname *

Legal Forename *

Chosen Name if Different from Legal Name

Date of Birth *

	DD/MM/YYYY

Gender as declared on birth certificate *

Male
Female
Prefer Not To Disclose

Home Language *

Admission Date *

	DD/MM/YYYY

Leaving Date

	DD/MM/YYYY

Social Care Status *

SEN Status *

K - SEN Support
E- EHCP
N - No SEN Identified