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This form, to be completed by the applicant's school, is ONLY for applicants applying under the Dyslexia (Significant Literacy Difficulties) category, who do not have a full Psychological Assessment Report identifying Dyslexia.

Please complete all sections below in TYPE or BLOCK capitals:

1. Applicant details

Full Name of Applicant

Date of Birth

CAO Number

2. School details

School details
School Name
School Address
Roll Number

3. Statement

We the undersigned declare that there is a current Student Support File in place which confirms that the applicant has a record of school-based interventions addressing persistent literacy difficulties.

We the undersigned agree that, to the best of our knowledge, all the information provided on this form is true, correct and complete.

Signature of Special Educational Needs (SEN) Teacher

Signature of Applicant	Signature of Parent/Guardian (if applicant is under the age of 18 on 1 February 2027).
Print name of Special Educational Needs (SEN) Teacher	School stamp


Print name of Principal/Deputy Principal
Signature of Principal/Deputy Principal	Date:

Signature of Principal/Deputy Principal