| No. in Admissions Registers: | 324 |
| Date of admission: | 15 January 1866 |
| Whence received: | Stafford |
| By whom brought: | - |
| On what terms: | - |
| Friends interested in him: | - |
| Description: | |
| Height: | - |
| Figure: | - |
| Complexion: | Pale |
| Hair colour: | Brown |
| Eyes colour: | Grey |
| Perfect vision? | Yes |
| State of health: | Good |
| Able-bodied? | Yes |
| Sound intellect? | Yes |
| Use of all limbs? | Yes |
| Had cow or small pox? | Vaccinated |
| Particular marks: | - |
| Cutaneous disorder? | No |
| Scrofulous or consumptive? | Not apparent |
| Subject to fits? | Not |
| Age last birthday: | 12 |
| Illegitimate? | - |
| Birthday: | - |
| Birth place: | - |
| Has resided: | Tipton |
| Parish he belongs to: | Great Bridge |
| Customary work and mode of life: | - |
| Schools attended: | - |
| By whom and where employed: | - |
| State of education: | |
| Reads: | Imperfectly |
| Writes: | Imperfectly |
| Cyphers: | - |
| General ability: | - |
| Offence: | Stealing money |
| Circumstances which may have led to it: | Destitution |
| Date of sentence: | 26 December 1865 |
| Where convicted: | Bilston before I Spooner |
| Who prosecuted: | - |
| Where imprisoned: | - |
| Sentence: | 31 days prison (hard labour), 5 years at Saltley |
| Previous committals and convictions: | None |
| Father's name: | David Sampson |
| Occupation: | Moulder |
| Residence: | Sheffield |
| Mother's name: | - |
| Occupation: | - |
| Residence: | - |
| Father's character: | Bad. Twice in prison. A drinker |
| Mother's character: | - |
| Parents dead? | Mother |
| Survivor married again? | - |
| Parents' treatment of child: | Bad. Deserted him |
| Character of parents | - |
| Parents' wages: | Not known |
| Amount parents agree to pay: | Current address not known. Enquiries to be made |
| Superintendent of police (to collect payments): | - |
| Relatives to communicate with: | - |
| Person making this return: | - |
| Estimate of character on admission: | - |
| Character on discharge: | - |
| When and how left the Reformatory: | - |
[No date] Emigrated to Canada
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