Parental Initial Enquiry Form

Potential students will only be offered a place at a Wider Ambition setting if they meet the following criteria:

Have a diagnosis of autism or present with characteristics consistent with autism, or present with Social, Emotional or Mental Health (SEMH) needs such as anxiety, sensory needs or low mood which may be co-morbid with autism.
Have the academic ability to follow an age-appropriate curriculum in the format offered at the setting and achieve at average or above-average levels.
Are unlikely to display behaviour at the setting which would impact on other students or themselves.
Are considered, at our sole discretion, to be someone who would benefit from attending the setting and for whose profile of needs the physical environment, social context, and embedded therapeutic offer are appropriate.
Are considered, at our sole discretion, to be someone whose attendance would not cause unreasonable detriment to existing students.
Are, or are expected to be, eligible for Local Authority funding via an Education, Health and Care Plan or can provide evidence of other means of funding a placement.

By submitting this form, you confirm that you believe that your child fulfils the above criteria.

Full Name of Potential Student

Potential student's preferred name

Address

Date of birth

Name of parent carer

Address, if different from above

Email Address

Home phone number

Mobile phone number

Preferred means of contact Preferred means of contact Call to home phone Call to mobile phone Text to mobile phone Email Post

Contact details for any other person with parental responsibility (optional)

Potential student's current school year

Name and address of potential student's current or most recent educational establishment

Is the student currently receiving Special Educational Needs (SEN) support? Please provide details.

Does the student have an Education, Health and Care Plan (EHCP)? Please provide details.

Please provide an overview of the student’s additional needs and any diagnoses.

If Wider Ambition receives a consultation from a local authority about the above young person, are you happy for us to respond to this? If Wider Ambition receives a consultation from a local authority about the above young person, are you happy for us to respond to this? Yes No

Where more than one person has parental responsibility, they should both provide consent where possible.

By submitting this form, you agree to the following:

I accept the Admissions Policy and the Data Protection Policy for Lokrum Fields, which I can access on the policies page of this site.

I give consent for personal information relating to me or to the above potential pupil to be processed accordingly.

I understand that if I do not want any personal information to be shared with the third parties listed in the Admissions Policy, I must notify Lokrum Fields in writing at the earliest opportunity.

If my child is over 13 years old, they have given their consent for me to include their personal data in this form.

You can download this form here.