We're really looking forward to welcoming your child onto The Literacy Pirates' online, after-school programme!We just need to gather a bit more information so that we can confirm your place. • • • • • Your Child's Details First Name Last Name • • • • • Home Address Post Code City • • • • • Your Child's Date of Birth SchoolPlease select... Barking Abbey School Brook House Primary School Chestnuts Primary School Christ Church (Streatham) Church Of England Primary School Dunraven School Earlsmead Primary School Gainborough Primary School Goresbrook Primary School Highgate Wood School Lea Valley Primary School Lordship Lane Primary School Risley Avenue Primary School Rushmore Primary School St Dominics RC Primary School St Francis De Sales Junior School St John's Angell Town Primary School St Scholastica's Primary School Stoke Newington School The Devonshire Hill Nursery & Primary School The Elms Academy Vauxhall Primary School Walnut Tree Walk Primary School Winston Way Academy Attending The Literacy Pirates Your child will attend one session a week. Which days could they attend? MondayTuesdayWednesdayThursdayFridaySessions run 4-6pm. We will allocate a day and let you know. We can also change the day if needed. • • • • • Will you require a laptop to be provided?YesNo Your Child's Emergency Contacts Who is your child's main emergency contact? First Name Last Name Relationship to ChildPlease select... Aunt Father Grandfather Grandmother Mother Other Brother Step-father Step-mother Uncle Family Worker Cousin Foster Carer Family Friend Guardian Godmother Godfather Sister Phone Number Email • • • • • Who is your child's second emergency contact? Full Name Relationship to ChildPlease select... Aunt Father Grandfather Grandmother Mother Other Brother Step-father Step-mother Uncle Family Worker Cousin Foster Carer Family Friend Guardian Godmother Godfather Sister Phone Number Email Your Child's Needs What is your child's first language? • • • • • Does your child have special educational needs?YesNo If yes, please provide details (e.g. dyslexia) • • • • • Does your child have any medical conditions?YesNo Details, including medication taken (please be specific) • • • • • Is there any other information about your child's educational, emotional, social, or behavioural needs that is useful for us to know? Monitoring Information Does your child receive free school meals?Please select... Yes No Prefer not to say • • • • • Is your child aPlease select... Boy Girl Prefer not to say Describe themself in another way Please describe here: • • • • • How would you describe your child's ethnicity?Please select... Arab Asian (Indian, Pakistani, Bangladeshi, Chinese) Asian British Asian Other Black African, Caribbean Black British Black Other Kurdish Latin American Mixed Asian, White Mixed Black, White Mixed Other Turkish White British White Other Other Prefer Not to Say • • • • • We collect this information to measure the success of our programme against national statistics, to monitor diversity, and to ensure that we are doing our best for all children. The information is confidential. Consent & Agreements I consent to the Terms and Conditions of the programme and I agree that a responsible adult will be present and close enough to be able to hear the session while my child takes part..Yes • • • • • I give permission for photographs and video footage to be used/included in our Young Pirate products, such as a published book and movie. YesNoAs part of the programme, your child will receive exciting opportunities to contribute to books and other products published by The Literacy Pirates. These are shared at closed events for the children, their families, their teachers and supporters. x I give permission for photographs and video footage of my child to be used by The Literacy Pirates for their charitable aims, in both displays and online. YesNoAs a charity, we need to market our work in order to raise funds and recruit supporters. This sometimes requires us to take photographs and videos our sessions to share in publicity material. x • • • • • First letter of your child's first name First letter of your child's last name • • • • • Signed (Full Name) Relationship to child: Date • • • • • If you have any special requirements regarding photo consent for your child, please get in touch. We will record them and ensure they are met. You can reach us at 07912 178037. Evaluation On a scale of 0 to 100, how would you rate your child's:motivationcare for workand ability to keep going? (0 is the lowest and 100 is the highest) • • • • • How do you think your child would describe themselves? Not a very good readerAn average readerA very good reader • • • • • How many books does your child own?01-45-910-1920+ • • • • • What do you hope your child achieves in their time with The Literacy Pirates? • • • • • We collect this information to track how much progress your child makes on the programme. The information is confidential. • • • • • Thank you for completing this form!Please press the Submit button below to send the form to us.
