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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

<div style="text-align: center;"><img src="imgs/img_in_image_box_853_1029_2289_1449.jpg" alt="Image" width="57%" /></div>


CAO Number

### 2. School details


<table border=1 style='margin: auto; word-wrap: break-word;'><tr><td colspan="2">School details</td></tr><tr><td style='text-align: center; word-wrap: break-word;'>School Name</td><td style='text-align: center; word-wrap: break-word;'><img src="imgs/img_in_image_box_849_1615_2303_2041.jpg" alt="Image"" /></td></tr><tr><td style='text-align: center; word-wrap: break-word;'>School Address</td><td style='text-align: center; word-wrap: break-word;'><img src="imgs/img_in_image_box_849_1615_2303_2041.jpg" alt="Image"" /></td></tr><tr><td style='text-align: center; word-wrap: break-word;'>Roll Number</td><td style='text-align: center; word-wrap: break-word;'></td></tr></table>

### 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.


<table border=1 style='margin: auto; word-wrap: break-word;'><tr><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td></tr><tr><td style='text-align: center; word-wrap: break-word;'>Signature of Applicant</td><td style='text-align: center; word-wrap: break-word;'>Signature of Parent/Guardian (if applicant is under the age of 18 on 1 February 2027).</td></tr><tr><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'>School stamp</td></tr><tr><td style='text-align: center; word-wrap: break-word;'>Print name of Special Educational Needs (SEN) Teacher</td><td rowspan="2"></td></tr><tr><td style='text-align: center; word-wrap: break-word;'></td></tr><tr><td style='text-align: center; word-wrap: break-word;'>Signature of Special Educational Needs (SEN) Teacher</td><td rowspan="2"></td></tr><tr><td style='text-align: center; word-wrap: break-word;'></td></tr><tr><td style='text-align: center; word-wrap: break-word;'>Print name of Principal/Deputy Principal</td><td style='text-align: center; word-wrap: break-word;'>Date: <img src="imgs/img_in_image_box_1358_3175_2304_3306.jpg" alt="Image"" /></td></tr><tr><td style='text-align: center; word-wrap: break-word;'>Signature of Principal/Deputy Principal</td><td style='text-align: center; word-wrap: break-word;'></td></tr></table>

Signature of Principal/Deputy Principal