Register of Disabled Children

Under the Children Act 1989

PERSONAL DETAILS
Child/ Young Person’s Family Name:
Forenames:
Previous Names (if any):
Date of Birth (DD/MM/YY): / Male /  / Female / 
Parent(s) /Carer(s) Name(s):
Address where child/young person is living (if at residential school, please give home address):
Telephone Number:
Racial Origin and Immigration Status
White / Black
British / A1 / Black or Black British Caribbean / D1
Irish / A2 / Black or Black British African / D2
Any other White background / A3 / Any other Black background / D3
Asian / Mixed
Asian or Asian British Indian / C1 / White and Black Caribbean / B1
Asian or Asian British Pakistani / C2 / White and Black Caribbean / B2
Asian or Asian British Bangladeshi / C3 / White and Asian / B3
Any other Asian background / C4 / Any other mixed background / B4
Other Ethnic Group / Immigration Status
Chinese / E1
Any other Ethnic group / E2
First language or method of communication
(e.g. BSL or Makaton) of the child/ young person:
Religion of the child/ young person:
DISABILITY AND HEALTH DETAILS
GP’s Name:
GP’s Address/ Practice:
Telephone Number:
Name of Health Visitor or clinic usually attended:
Please describe the child/ young person’s disabilities/ special need:
Does your child have a special medical diagnosis/ condition? / Yes /  / No / 
If yes, please state all e.g. cerebral palsy, sickle cell:
Which of the following category or categories would most closely describe the child/ young person’s need (please tick all that apply and circle 1,2,3 or 4 to show the severity for each).
Physical /  / 1 / 2 / 3 / 4 / Mental health /  / 1 / 2 / 3 / 4
Sensory – hearing /  / 1 / 2 / 3 / 4 / Emotional & behavioural /  / 1 / 2 / 3 / 4
Sensory – visual /  / 1 / 2 / 3 / 4 / Communication /  / 1 / 2 / 3 / 4
Learning difficulty/disability /  / 1 / 2 / 3 / 4 / Other
Please state: /  / 1 / 2 / 3 / 4
Chronic medical need /  / 1 / 2 / 3 / 4 / ______
1 = Mild 2 = Moderate 3 = Severe 4 = Profound

Please enclose medical evidence, such as GP Reports, Hospital Reports.

AGREEMENT BY CHILD/ YOUNG PERSON/ PARENT OR OTHER PERSON WITH LEGAL RESPONSIBILITY FOR THE CHILD/ YOUNG PERSON
I, ………….………..…….. (please print name) confirm that the information provided on this form
is correct and that the child/ young person'’ name can go on the Register of Disabled Children.
I understand that the Register will be used for planning purposes by Brent Council.
Signature: ______Date: ______
Details of Person authorising the registration::
Name:
Relationship to child/ young person:
Address:
Telephone Number:
Translations:
Do you require information to be translated? / Yes /  / No / 
If yes, please state language:

If you have any questions about completing this form, please contact us on 020 8937 4700/4463 and enclose ONE PASSPORT SIZED PHOTOGRAPH OF YOUR CHILD.

Once you have completed this form, please return it to:

Register of Disabled Children

Children with Disabilities Team

Brent Children and Families

Brent Civic Centre

Engineers Way

HA9 0FJ

For office use only:
Date first entered on the register:
Last date information updated:
Register reference number:
Information transferred to the Register for Adults with Disabilities: / Yes /  / No / 

FOR BRENT COUNCIL USE ONLY

1

Access to Personal Files Act 1987

Clients of this Department are encouraged to have access to all information stored on their personal files. Please indicate clearly on any information, report, minute, letter which you do not wish to be shared with the client RESTRICTED FROM CLIENT ACCESS. It would be helpful to this Department if you would indicate the reasons for the request for restriction.