Dear Parent,

In line with Department of Health Guidance, it is important that we hold a record of those people who have parental responsibility for all the children (under 16 years) registered with our surgery.

By parental responsibility, we mean all the rights, duties, powers and responsibilities which by law a parent has in relation to a child.  This will include any of the following:

  • The child’s mother 
  • The child’s father if married to the mother at the time of the birth, or if they married after the birth.  
  • The father if he co-registered the child’s birth with the mother and the registration took place after 1.12.2003
  • The father if he has registered a Parental Responsibility Agreement with the court
  • A civil partner:
    – if she is in a civil partnership with the mother at the   time of the birth
    – if she registers a civil partnership with the mother later on,
    – if she is on the UK birth certificate
    – if she and the mother have signed a parental responsibility agreement, which is a – prescribed form, and lodged it with the court; or
    – if the court has made a parental responsibility order in her favour.
  • A person granted a court order under the powers of the Children Act 1989
  • A person who has been appointed a guardian by the court under the Children Act 1989

Please complete the attached form, letting us know who has parental responsibility for your child.

This information will be held on your child’s medical record.  If there are any changes to the details, please let us know as soon as possible.

If you have any queries, please email

Your Details

DD slash MM slash YYYY

Declaration of Parental Responsibility

Child's Name(Required)
DD slash MM slash YYYY
DD slash MM slash YYYY
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