To be completed for all Children under 16 Years

A report commissioned by the Government into the death of Victoria Climbie, a child who was neglected by her guardians and subsequently died, has led to the implementation of recommendations to professionals such as GPs, to ensure the safety of all children. One of these recommendations is that we gather the following information about all registering children under the age of 16. Please help us to do this by confirming the correct information about your child. All information will be held confidentially within the practice and will only be passed to other health care professionals in cases of medical concern or a potential risk situation.

Last Updated: 15/09/2021

Patient Details

Child Full Name *

Date of Birth *

Gender *

Male

Female

Please state the child's ETHNICITY *

Parental Responsibility

It is important that we ascertain who has parental responsibility for all children under 16. If you are unsure please see below • Mothers and married biological fathers automatically have Parental Responsibility and will not lose it if divorced. • Unmarried biological fathers do not automatically have Parental Responsibility unless they have registered their name on the birth certificate. • Step-fathers and Step-mothers do not automatically have Parental Responsibility. • Grandparents do not automatically have Parental Responsibility • Foster carers do not hold Parental Responsibility (but will hold a degree of delegated authority to make routine decisions around a child’s health) • The Local Authority will share Parental Responsibility with the parents if on a Care Order. • A child can be accommodated by a Local Authority but not be subject to a care order or placement order. Where a child is voluntarily accommodated by a Local Authority under a section 20, Parental Responsibility remains with the parent; the Local Authority does not share Parental Responsibility but the child is still ‘Looked after’. • A Special Guardianship Order grants Parental Responsibility to the child’s ‘special guardian’ ** Please note: where any biological parent is not indicated above (birth mother, father if named on birth certificate) we are still unable to deny any access requests unless relevant legal court evidence is provided.

Full name of person with parental responsibility *

Relationship to child *

full name of person with parental responsibility

Relationship to child

Who does the child reside with all or most of the time? *

School/Nursery/Childcare Details

We need to know where your child attends full/part time education or childcare

Name of School/ Nursery/Childcare setting

Type

Medical Conditions

Please tell us if your child has any current medical conditions

Medication

Please tell us of any current medication your child is taking

Electronic Signature

Please type your name below as your electronic signature *

Please confirm that you have parental responsibility for the child *

Yes No

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To be completed for all Children under 16 Years

Further Information