Paragraph 1
The following statement is made by [here insert name of Education and Library Board] in respect of the child whose name and other particulars are mentioned below. This statement is in accordance with Article 16 of the Education (Northern Ireland) Order 1996 (“the 1996 Order”) and the Education (Special Educational Needs) Regulations (Northern Ireland) 2005 (“the Regulations”).
Child
| Surname | Other names |
| Home address | |
| Sex | |
| Religion | |
| Date of Birth | Home language |
Child's parent or person responsible
| Surname | Other names |
| Home address | |
| Relationship to child | |
| Telephone Number |