Tuition Enrolment Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Education Provider Details Current School Name: *Previous School Name: *Current School Address: *Previous School Address: *Referrer Details Name of Referrer: *Position of Referrer: *Referrer Contact Details: Email *MobileOffice Address *Postcode *Parent/Carer Details 1 Name of Parent/Carer: *Parent/Carer Contact Details: Email: *Office Mobile: *Parent/Carer Details 2 Name of Parent/Carer: *Parent/Carer Contact Details: Email *OfficeMobileStudent Details Name of Student: *Student DOB: *Preferred Name: *Year Group: *Student Gender: *MaleFemaleEthnicity: *Preferred Language: *Home Address: *SEND / Disability: *YesNoIf yes; please highlight:Highlight:Physical DisabilityEHCP / SEN SupportMedically illStudent Behaviour Summary: Number of Hours per week:Outcome required:Location:Social Services Support Does the student have a child protection plan? *YesNoDoes the student have a CIN plan? *YesNoIs the student looked after (LAC)? *YesNo*Please attach relevant reports/documents *Academic Attainment KS2 SATS KS3 SATS Math’s LevelMath’s LevelEnglish LevelEnglish LevelScience LevelScience LevelStudent Tuition Requirements Summary: *Please include: (Subject/s, Number of Hours per week, preferred day and time of tuition). Academic Attainment KS2 SATS KS3 SATS Math’s Level: *Math’s Level: *English Level: *English Level: *Science Level: *Science Level: *Risk Assessment Form CONFIDENTIAL Name of student *Date of birth *NC Year *Risks identified – Location Premises Is the address known to police?YesNoAre the premises isolated?YesNoDo person/persons at the address have a history of violence, aggressive behaviour, or domestic violence?YesNoDo person/persons at the address have a history of allegations against professionalsYesNoAre there potentially dangerous animals or pets at the premises?YesNoRisk identifiedAssessment of Current/Anticipated Risk(s)Action Plan Tuition to take place at kitchen tableBy whomBy whenKitchen surfaces to be free of items that could cause harm (e.g., hot water in kettle, saucepans/iron, knives/knife block)By whomBy whenTutor to sit by kitchen door with Pupil sitting opposite and behind the tableBy whomBy whenKitchen door to be kept openBy whomBy whenFront door to be kept unlockedBy whomBy whenUseful information (E.g., location of key documents, network contact details) Tutor to leave premises if any threat/danger anticipatedEmergency services to be calledRisk assessment shared and agreed NameSignedDate address isolated? kept Nominated Person to Authorise Invoice: Name of Authorized Person : *Position of Authorized Person: *Authorized Person Contact Details: Email *MobileOfficeAddressPostcodeTerms & Conditions *I have read & agree to the Terms and Conditions of Jus‘T’Learn Tuition Centre.Submit
