Home Education Application Form

1 Child's Personal Details

Child's name *

First

Last

Date of birth *

Gender *

Female Male Other Prefer not to say

Nationality *

Is the child a UK resident? *

Yes No

If no, please provide more information

Address *

Has the child ever had any involvement with external agencies, either currently or in the past? *

Yes No

For example — Social Care, Early Help, CAMHS etc.

If yes, for child safeguarding purposes, please provide more information

All information provided will follow GDPR guidelines and procedures.

Does the child have any criminal convictions? *

Yes No

If yes, please provide more information

All information provided will follow GDPR guidelines and procedures.

2 Medical History

Are there any current medical conditions or allergies affecting the child that we need to be informed of? *

Yes No

If yes, please provide further information

3 Parent / Guardian Details

Parent / guardian's name *

First

Last

Parent / guardian's contact number *

Parent / guardian's email address *

Relationship to child *

4 Education

Which year group will the child be in as of September 2026? *

For all late referrals involving Year 11 students, please select 'School Leaver'.

Name of previous education attended *

Which course are you applying for? *

Does the child currently have an EHCP or learning needs? *

Yes No

If yes, please provide more information

5 Permissions

Do you give Ashley Jade Education Group permission to…

Please answer Yes or No to each. We'll only ever use these in line with our privacy policy.

Use photographs and videos of the child for educational purposes* Some images will be required as evidence for assignments within the qualification.

Yes No

Use photographs and videos of the student for social media and promotional purposes*

Yes No

Access your Personal Learning Record (PLR)* Your PLR includes your Unique Learner Number (ULN), used to register you for qualifications, plus previous achievements (e.g. GCSEs).

Yes No

6 Professional Persons Only

If you are completing this referral on behalf of an external agency, please complete the information below.

Name of the professional completing this referral

First

Last

Email address of the professional completing this referral

Name of the school or external agency you are representing

Home Education Application Form

1 Child's Personal Details

2 Medical History

3 Parent / Guardian Details

4 Education

5 Permissions

6 Professional Persons Only

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