St. Marys N.S.

Ballinagare
Co. Roscommon
http://ballinagarens.scoilnet.ie/ http://ballinagarens.weebly.com/

Ph: 094 9870564

Email: ballinagarens@eircom.net

Application Form
Name:
Sex:
PPS Number:
Date of Birth:
Age at School Entry (Years
and Months)
Address:

Mothers Name:
Fathers Name:
Home Phone Number:
Mothers Mobile:
Fathers Mobile:
Under Family Law is there a
legal document the school
should know about?
If yes please provide a copy.
Religion:
Place of Baptism:
If not in Ballinagare please supply
copy of Baptismal Cert.
Mothers Occupation:
Fathers Occupation:
Number of children in
family:
Has your child attended
preschool previously?
 Name of preschool and duration

Developmental Checklist
Please tick Normal Unusual Comment

Birth History
Developmental
Milestones
Walking
(by 18 months)
Talking
(by 2 years)
Toilet Training
(by 3 years)

Please state any

medical or health
problems your child
may have:

Has your child an

allergy/condition the
school should be
aware of?

Does your child take

any medication the
school should be
aware of?

Please state any

additional needs your
child may have:

Does your child have

an assessment of
needs?
If yes, please give detail.
Referral to any other
outside agencies:
(e.g. speech therapy, social
worker, psychologist,
specialist)
 Please tick Satisfactory Unsatisfactor Comment
y

Vision

Hearing

Physical
Co-ordination

Speech

Language

Temperament

Sociability

Concentration

General Alertness

Any other
information/
comments

I consent for this information to be stored on the Primary Online Database (POD) and transferred
to the Dept. of Education and Skills and to any other primary schools should my child transfer to
during the course of their time in primary school

Signed: ______________________________________ Date: __________