Bertha the Queen, Cumberland Avenue
Canterbury, Kent CT1 1SL
Telephone: 01227 450740
Email: info@activelives.org
Student Placement / Transport Application
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Student and Other details
Student Name
*
First
Last
Student age
Student date of birth
Day
Month
Year
Next of kin Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Next of kin telephone number
*
Students current address (if different from above)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Students telephone
*
Care manager name
*
First
Last
Care manager address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Care manager telephone
Medical information
Name current G.P.
First
Last
Address current G.P.
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Telephone current G.P.
Special medical needs (if any) / Details of current medication
Allergies or reactions (if any)
Other information
Special dietry needs (if any)
Hobbies and interests
Likes and dislikes
Additional information
Please use this space to provide any additional information about the student you feel may be relevant
Signed (please print name)
*
Are you:
*
Student
Parent
Guardian
Today's Date
*
DD slash MM slash YYYY
Name
This field is for validation purposes and should be left unchanged.
Bertha the Queen, Cumberland Avenue
Bertha the Queen, Cumberland Avenue