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Your name *

Title

Relationship to Student: *

Student's Name: *

Student's DOB: *

Student's DOB in DD/MM/YYYY format. Please use / to separate.

Student's School Year: *

Student's Gender: *

Female
Male
Other

Parent's Address: *

Parent's Email: *

Parent's Daytime Telephone: *

Parent's Evening Telephone:

Do you speak fluent English? *

Yes
No

If not, what is your first language?

School Name: *

Type of school: *

Academy
Independent
Maintained/Comprehensive
Other
PRU

Headteacher's Name:

School's Address:

School Telephone Number:

What date was the exclusion made on? *

Enter date in format DD/MM/YYYY

Is the exclusion permanent of fixed term (for a specific number of days)? *

Please note we can only assist with permanent exclusions.

Permanent
Fixed

Please provide a short summary of events that led to the exclusion: *

Student bullied before exclusion?

If so, please give further details

Are there/have there been any criminal proceedings in relation to the event or events leading to the exclusion? (If so, please specify.) *

Was a managed move attempted? *

Yes
No

Please provide details of the managed move attempt:

Has the Governors' hearing taken place? *

Yes
No

If not, has it been arranged? *

Yes
No

Date of hearing: *

Enter date in format DD/MM/YYYY

Time of hearing:

Location of hearing:

If you have already lost the GDC, do you want to appeal to an IRP? *

Yes
No

Has the IRP been applied for? *

No
Yes

Has the IRP been arranged?

No
Yes

Date of hearing: *

Enter date in format DD/MM/YYYY

Time of hearing:

Location of hearing: *

Have any other meetings taken place or been arranged? *

If yes, please provide details:

Does your child have any Special Educational Needs (SEN)? *

No
Yes

Please provide details of their SEN:

Were their needs being addressed at:

No Support
School Action
School Action Plus
Statement/EHC

Do you consider your child to have a disability?

No
Yes

Please provide details of their disability:

Please specify whether any other organisations are, or have been, providing you with advice or support.

How did you hear about our services?

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