Select club Select clubSuper Stars Club - FOUR DWELLINGS ACADEMYSuper Stars Club - ALLENS CROSSMedia Madness - FOUR DWELLINGS ACADEMY

Your full name

What is your e-mail address? We need this to inform you if you are successful in gaining a place

What is your Mobile Number? We need this to inform you if you are successful in gaining a place

Your child's full address?

Postcode

About your child

Child's first name

Child's last name

Gender GenderMaleFemale

Child's date of birth (e.g._01/04/1980)

Child's shoe size

Name of School (Please type the full school name)

Does your child receive free school meals? Does your child receive free school meals?YesNo

Free school meals code (This can be obtained directly from your child's school)

Does your Child have a spectrum diagnosis? Does your Child have a spectrum diagnosis?YesNo

Is your child receiving SENCO support from their school? Is your child receiving SENCO support from their school?YesNo

Does your child have a EHCP (Educational Health and Care Plan) Does your child have a EHCP (Educational Health and Care Plan)YesNo

Emergency Contact Details

Name of first emergency contact

Contact number

Relationship to child

Contact number 2

Name of second emergency contact

Relationship to child 2

Additional information

Ethnicity EthnicityAsian/Asian British – OtherBlack/Asian/Caribbean/Black British AfricanBlack/Asian/Caribbean/Black British – OtherMixed/multiple ethnic groups White and AsianMixed/multiple ethnic groups White and Black AfricanMixed/multiple ethnic groups White and Black CaribbeanMixed/multiple ethnic groups – OtherWhite – Welsh/English/Scottish/Northern Irish/BritishWhite – IrishWhite – Gypsy, Roma or Irish TravellerWhite – Eastern EuropeanWhite – OtherOther Ethnic group – ArabAny other Ethnic Group

Disability

Does your child have any medical conditions we need to know about? Please type None if no.

Please tell us about your childs behaviour

Special educational needs

Please tell us about your child's Special educational needs Please tell us about your child's Special educational needs No meat Vegetarian Diary free Egg free Wheat free Gluten free Halal Kosher Vegan No pork My child does not have a dietary requirement

If your child has a sibling/siblings that you are also applying for, please type there FULL name/s and date of birth's.You will need to complete a separate form for any siblings.

Tick boxes - all mandatory Tick boxes - all mandatory I consent to photos & footage being taken of my child and used on the FTLOS Birmingham website (Our registered company), social media platforms, marketing & shared with Schools I consent to sharing and seeking information with my childs school for the purposes of enhancing my child's experience whilst at the club I give medical consent in the case of an emergency I agree to collecting my child/ children on time each day

You will be notified by E-mail if your child is successful in gaining a place at your chosen within 1 week of your submission. Please make sure to check your spam folder.