Statement of interest in joining the Periplus Free School

Completion of this form does not formally commit you to applying for, or accepting, a place at the proposed state funded Internet school. However it will be taken as evidence of your genuine interest in the proposal. If you require any further information before completing this questionnaire please contact Periplus at info@periplus.org.uk or call us on 0207 843 5891.

The forms will remain confidential to Periplus and those compiling the application for the school. No individual form will be submitted to the DfES or used in any way, other than to support the named child at the time of enrolment if the application is successful. If the application is unsuccessful, all forms will be destroyed unless we are given permission to resubmit the application for a 2013 start. The questions are all intended to provide evidence to build the case for the school.

1. Name of Parent (s) *This question is required.

2. Address of Parent (s) *This question is required.

3. Email of Parent *This question is required. This question requires a valid email address.

4. Name of Child *This question is required.

5. Gender of Child *This question is required.

6. Child's date of birth *This question is required.

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7. Age of Child in September 2012 *This question is required. This question requires a valid number format.

8. Date on which home education commenced *This question is required.

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9. Was a Local Education Authority or School Notified of the decision to home educate? (there is no requirement to answer this question)

10. Please give details of Local Authority or School so advised (there is no requirement to answer this question)

11. Please outline your reason at the time (if applicable) for de-registering your child *This question is required.

12. Please give, in outline, the format of the current provision made for home education, including the structure of a typical day, any resources you have needed to purchase, tutor support or other regular additional input for which you pay *This question is required.

Information provided in response to the following questions is totally confidential and will NOT be used as part of the selection criteria for admission. It's sole purpose is to provide, without any reference to any individual, evidence to ensure the proposal, as submitted, will enable us to meet the needs of those likely to be admitted).

13. Have you ever been advised by a school that your child is on the special needs code of practice or has a statement of additional need? *This question is required.

14. If yes (or you believe this to be the case) please provide, in outline, the details

15. If your child was attending a state school at present do you know /believe that you would qualify for free school meals based on income/benefit criteria *This question is required.

16. If you would be interested in committing further time to helping develop the more detailed proposals required if the initial application is approved, or you have particular skills or interests that you think could be of benefit to such a future school and which you are willing to share, please provide details below.

N.B. If the application for the school is successful, and you would like your child to be enrolled, it will be necessary to prove residency and a right to education in the UK

Statement of interest in joining the Periplus Free School

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