Treloar’s • Holybourne Alton Hampshire GU34 4GL • T 01420 547400 • E admissions@treloar.org.uk • www.treloar.org.uk Charity number.1092857

Please check that you have completed this form as fully as possible and that you have retained copies of all reports you need to send. Please return this form and all other information to: Admissions, Treloar’s, Powell Drive, Holybourne, Alton, Hampshire, GU34 4GL

Treloar School and College application form Treloar’s strives for excellence in education, therapy and care in environments which encourage disabled individuals to achieve their potential.

Proposed year of entry (e.g. 2017):
Student Name:

Please note that it is extremely important that we receive copies of all available reports in advance of assessment. We will not be able to progress your application if you do not send copies of all available reports.

Please indicate which reports are available and enclose copies of those available: Available Not Available Section 139a Assessment/most recent SEN/EHCP Physiotherapy assessment * Annual Review/SEN * Speech & Language assessment * Most recent School report Occupational Therapy assessment * Most recent Medical report Psychiatry assessment * Educational Psychologist report * Behavioural plans * Visual Impairment report * Exam results slips/certificates * Other (please list and enclose) * if applicable
Information on this form is provided by: Name(s) IN CAPITALS:
Address and telephone if different from that stated on page 3:
Signature(s)	Date:
WHAT TO DO WITH THE COMPLETED APPLICATION: Please check that you have completed this form as fully as possible and that you have retained copies of all the reports you need to send. Please return this form and all other information to: Admissions, Treloar’s, Powell Drive, Holybourne, Alton, Hampshire, GU34 4GL
DATA PROTECTION Treloar School & College adheres to the 1998 Data Protection Act. The information we are asking you for may be placed in a manual file, placed on a computer database and passed to other individuals both internally and externally who are involved with the applicant. We are required by law to pass on certain information to the provider of youth support in your area. This is the local authority support service for young people aged 13 to 19 in England. We must provide your address, your date of birth and any further information relevant to the support services’ role. By signing/completing this form you are agreeing to the above statement. If you do not agree to any aspect of this please indicate here

1. ABOUT THE APPLICANT
Surname:	First names:
Known as/familiar name:	Age:
Date of birth:	Male Female Transgender
No. of brothers and sisters:	Position in family: e.g. oldest/youngest
National Insurance No:	Country of birth:
Nationality (including dual nationality, if applicable):
Language used at home:	Free School Meals: Yes No
Details (if applicable) of custody, care, fostering, etc.:	‘Looked After Child’	Yes No
‘Child in need’	Yes No
Home address:
Postcode:
COLLEGE ONLY DATA PROTECTION – from time to time the Education Funding Agency (EFA) may wish to contact learners. Please indicate below whether you are happy to be contacted. Learner has withheld permission to be contacted Learner has only withheld permission to be contacted about course or learning opportunities by post Learner has only withheld permission to be contacted for survey and research No Restrictions
Are you looking for: Day Placement Weekly boarding (Mon-Thurs) Weekly boarding (Sun-Thurs)
Termly boarding Non-term time provision (please specify requirements):
Other (please specify requirements):
Are you looking for occasional/regular respite for evenings/weekends?
Current School/College Year Group?
Principal Disability: Note that there is space for additional medical information on page 6
Additional Disabilities:

2. NAME(S) of PARENT(S) or CARER(S)
NAME:	Relationship to applicant:
Address	CONTACT DETAILS
Home telephone:
Work telephone:
Mobile telephone:
E-mail address:
Emergency contact no:
NAME:	Relationship to applicant:
Address	CONTACT DETAILS
Home telephone:
Work telephone:
Mobile telephone:
E-mail address:
Emergency contact no:
Tick here if a second copy of student reports should be sent to the second address.
3. EDUCATION
Current / Last School: Name:	Date Left / Due to Leave:
Address:
Postcode:
Contact name:	Telephone:
Name and address of Local Authority (LA):

Does the applicant receive additional support in the classroom? Yes No
If YES, how much, and what is the nature of the support?
Is the applicant disapplied from any part of the National Curriculum? Yes No

It is important to complete this section fully

SCHOOL APPLICANTS (State National Curriculum/P Levels in): English Level:	Maths Level:	ICT Level:
We follow the National Curriculum, adapted and modified according to student need. Please indicate any subject areas of specific interest:
Details of any accredited courses that have been started (if applicable):

COLLEGE APPLICANTS (State National Curriculum / P Levels in): English Level:	Maths Level:	ICT Level:
Details of previous accreditation including any GCSEs, or other qualifications taken or to be studied:
Possible areas of interest at Treloar’s: Art, Design & Photography Cookery/Nutrition Enterprise, Employability and Personal Finance Enterprise Skills Sports Leadership Apprenticeship/Internship/Traineeship Business Studies Art/Craft/Textiles Community/Life Skills Range of subjects/levels at Alton College Sensory Programme Independent Advocacy
Likely level of study: Pre-entry Entry Level 1 Level 2 Level 3 Other

Note Please send in details from the school detailing the applicant’s academic achievements to date and predicted results if applicable. If we do not receive this information we may contact the applicant’s current or previous school to confirm this prior to processing the application.
4. LEISURE INTERESTS & ACTIVITIES, SPORT, HOBBIES, CLUBS
5. MEDICAL DETAILS
Name of General Practitioner (GP):	NHS Number:
Address:
Postcode:	Telephone:
This is important information and can be obtained from your home area GP. Clinical Commissioning Group (CCG):
Address:
Postcode:	Telephone:
Name(s) of Consultant(s):	Address and telephone:	Specialist area: E.g. Orthopaedic, Paediatric, etc.
Does the applicant have, or require treatment for, any of the following? If YES, please give brief details.	YES	NO
Epilepsy
Diabetes
Asthma
Eczema
Heart condition
Visual Impairment
Hearing Impairment
Allergies
Regular and/or significant pain
Memory Deficit
Perceptual Deficit
Other (please specify here):

6. MEDICATION
Drug	Dosage	When and how administered
Please use a separate sheet if you require more space. Tick here if you have included a separate sheet.

7. DIETARY / FEEDING REQUIREMENTS
Please give details of any special dietary requirements, food allergies, swallowing difficulties or special feeding arrangements, including gastrostomy or other tube feeding:
Mealtime Support Please give a brief description of mealtime assistance if needed, including any equipment required at meal/snack times?
Approximate typical time taken for a main meal:
DIETETIC SUPPORT	Yes	In the past	No
Does the applicant see a Dietician?
Name and Address of current Dietician’s clinic:

8. THERAPY
PHYSIOTHERAPY	Yes	In the past	No
Does the applicant receive Physiotherapy?
Name of current Therapist:	Telephone:
E-mail:
Therapy involved and frequency of treatment:
SPEECH AND LANGUAGE THERAPY	Yes	In the past	No
Does the applicant receive Speech and Language Therapy?
Name of current Therapist:	Telephone:
E-mail:
Therapy involved and frequency of treatment:
OCCUPATIONAL THERAPY	Yes	In the past	No
Does the applicant receive Occupational Therapy?
Name of current Therapist:	Telephone:
E-mail:
Therapy involved and frequency of treatment:
OTHER THERAPY/HEALTH PROFESSIONAL INPUT
Please give details of involvement from other therapist(s) – e.g. counsellor, art or music therapist, visual impairment adviser, ophthalmic specialist, audiologist:

9. BEHAVIOUR
Yes	No	Please give details when appropriate
Does the applicant have an awareness of danger?
Does the applicant exhibit any self-injurious behaviour?
Are there any situations in which the applicant may be vulnerable?
Is there a history of aggressive behaviour towards:
a) Peers	a)
b) Staff	b)
c) Parents/carers?	c)
Is the applicant looked after or been previously looked after by the local authority (in care)?
If under 18, is there any Family Court order in respect of the applicant?
Please detail any difficult behaviour the applicant may present, factors that trigger it and strategies used to modify it:
Has the applicant ever been the subject of any child protection or adult safeguarding enquiry? Please give details:
9a. MENTAL CAPACITY
In your opinion, does the applicant have the mental capacity to make decisions about their care, health, education and residence? Please give details.
Does anyone hold a registered Power of Attorney in respect of the applicant? Please give details.
Is there a Court of Protection decision or current application to the Court in relation to the applicant? Please give details.

10. SKILLS, INDEPENDENCE & SOCIAL INTERACTION
Primary mobility please tick () 1 only: Fully ambulant Walks with crutches/aids Manual wheelchair user Powered wheelchair/scooter user Attendant-controlled wheelchair user Other
Local Wheelchair Centre Address::
Does the applicant have:	Yes	No	Please give details when appropriate
A loaned manual wheelchair? (please circle where appropriate)	NHS/shared/independently purchased
An EPIOC (Electrically Powered Indoor/Outdoor Chair)? (please circle where appropriate)	NHS/shared/independently purchased
Is the applicant able to:	Yes	No	Please give details when appropriate
Drive a powered wheelchair independently?
Use a manual wheelchair independently?
Walk unaided?
Go out alone in the community?
Communicate so as to be easily understood?
Understand verbal information in line with other abilities?
Use signing or gesture to communicate?
Does the applicant:	Yes	No	Please give details when appropriate
Interact with adults only?
Prefer his/her own company?
Occupy himself/herself?
Enjoy being part of a group?
Has the applicant:	Yes	No	Please give details when appropriate
Stayed away from home before?
Boarded before?
Ever shared a room?
Had difficulty when staying away from home?
SLEEPING
Does the applicant:	Please give details
Sleep in: an adjustable bed a standard bed?
Sleep with: a pressure relief mattress another type of mattress?
Sleep with: side rails support bars other bed accessories?
Require intensive supervision at night? Yes No
Please give details of any bedtime/morning routines:
CONTINENCE
Does the applicant:	Yes	No	Please give details/manufacturer
Use the toilet independently day and night?
Have a catheter, colostomy or anything needing specialist care?
Indicate the need for the toilet?
Sit on the toilet?
Need incontinence pads during the day / night?
Need toileting at night?
11. APPLIANCES AND EQUIPMENT
MOBILITY (Please tick boxes () and give details/manufacturer as appropriate)
Does the applicant use:	Yes	No
Scooter?
Walking aid?
Seating systems?	Is the applicant happy with them? Yes No
Switches?	Is the applicant happy with them? Yes No
BATH Standard Parker Aquanova Other:
SHOWER Walk-in Drop-down seat Fixed seat Shower chair other:
TOILET Clos-o-mat support bars special e.g. Chailey/Crossland other:
TRANSFERS Sliding sheet Turning sheet other:
Sling make and model:
Is the applicant able to do a standing transfer? Yes No Is a hoist needed? Yes No
IN THE CLASSROOM
Computer: Joystick Trackerball Standard Mouse Switch(es) Other: (please give details)
Does the applicant mainly: Handwrite Type other:
Does someone else write or type for the applicant? Yes No (please give details)
Does the applicant use specialist software to read and/or to produce work on a computer, e.g. Clicker/Penfriend? Yes No (please give details)
COMMUNICATION
Does the applicant use any equipment/aids to support their communication? Yes No
Please tick any equipment used for communication and give details…
Specialised communication device: (please give details)
iPad/tablet computer: (please give details)
Smartphone/iPhone: (please give details)
Communication software/Apps: (please give details)
‘Low-tech’ e.g. symbol communication book, alphabet chart: (please give details)
How is this equipment accessed? (e.g. direct access, switches) (please give details)
Is this equipment/software owned by the applicant? Yes No
Please give date equipment/software was purchased:
Please state who funded the equipment, if applicable:
Does the student use manual signing? Yes No
If Yes, which signing method is used at present (e.g. Makaton, BSL)? Used at school:
Used at home:
PLEASE NOTE: If the applicant uses any communication equipment/aids it is ESSENTIAL that you bring them with you to the assessment.
Details of any other important equipment:

12. SOCIAL SERVICES
Name of Social Worker:	Telephone:
Address:
E-mail:
Please attach copies of any reports produced by Social Services.

13. CAREERS
Name of PA (Careers Adviser) formally Connexions:	Telephone:
Address:
E-mail:
Please attach a copy of LDA/EHCP/SEN Final Year Assessment ( if available)

14. EXPECTATIONS
Applicant: Why do you think Treloar School/College is the right placement for you?
Parent(s)/Carer(s): Why do you think Treloar School/College is the right placement and what are the three main priorities for your child?
Any other information which may be helpful during the interview:
Please indicate how you heard about Treloar’s: Advert Directory (please specify) Disability Support Group Exhibition (please specify) Internet/website Parent of present or former pupil	Local Authority Other Professional/Specialist Current school or college Reputation Press article (please specify) Other (please specify)
AND FINALLY … please ensure you have completed the checklist at the front of this document and signed the form.