Shropshire Council May Amend This Form Subject to Legislations, Eligibility and Availability

Version 8 (March 2016)

Registration Form

This form is to be completed to ensure your child/young person is eligible to take part in any ‘All In’ Short Break activities and will be treated in the strictest of confidence. Any information contained will only be shared within the Short Breaks project and with providers of the activities that your child attends.

Shropshire Council may amend this form subject to legislations, eligibility and availability.

Child/Young Person’s Name:
(First name, middle name and surname)
Date of Birth / Age
Name of nursery / school / college
Ethnicity
(Please Circle) / White English / White Scottish / White Welsh / Other White British / White Irish / Traveller of Irish heritage / Gypsy/Roma / Other White / White & Black Caribbean / White & Black African / White & Asian / Any other mixed background / Black or black British Caribbean / Black or black British African / Black or black British any other black background / Asian or British Asian Indian / Asian or British Asian Pakistani / Asian or British Asian Bangladeshi / Asian or British Asian any other Asian background / Chinese / any other ethnic background
Parent/Carer
Names
Address
Daytime Tel No.
Evening Tel No.
Mobile Tel No.
Email Address for future
‘All In’ information to be sent to

Emergency Contact Details:

In the case of an emergency, we will first try to contact parents/carers on the above details. If we are unable to contact them we will require additional contact names and numbers.

Name (1)
Contact Number/s
Relationship to child/young person
Name (2)
Contact Number/s
Relationship to child/young person

Child/Young Person’s disability / additional needs:

What is your child/young person’s disability / additional need:

…………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Please tick if your child/young person is supported by School Action / School Action plus /

SEN Support

Please tick if your child/young person is supported by a Statement of Educational Need of

Education, Health and Care Plan (EHP)

What level of support does your child/young person require? (child:adult)

1:2 1:1 2:1 3:1 4:1 small groups

If other, please give details:

……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Does your child/young person require special equipment to aid their mobility?

…………………………………………………………………………………………………………………………

Does your child/young person require assistance with personal care?

(If yes, please state what care)…………………………………………………………………………………………

Does your child/young person have any feeding or eating issues/problems?

…………………………………………………………………………………………………………………………

Does your child/young person use any communication aids? (E.g. Makaton, Pecs)

…………………………………………………………………………………………………………………………

Please explain in detail any regular behaviour’s that your child/young person may show: (If your child has no behavioural problems please state ‘No Behaviours’ rather than leaving it blank)

How would you normally deal / respond to these behaviours?

How well does your child/young person respond to adults?

…………………………………………………………………………………………………………………………

How well does your child/young person respond to other children/young people?

…………………………………………………………………………………………………………………………

Please list any ways of stimulating / encouraging your child/young person that you have found useful:

…………………………………………………………………………………………………………………………

Behavioural techniques that your child/young person does not respond to:

…………………………………………………………………………………………………………………………

What are your child/young person’s interests, talents?

…………………………………………………………………………………………………………………………

What do you and your child/young person hope to gain from participating in the ‘All In’ activities?

Medical Information:

GP’s Name / GP Practice
Address
Telephone No.

Is your child/young person receiving medication? YES NO

If yes what type of medication:

Will the medication need to be administered during activities? YES NO

If yes please give details:

Does your child/young person have epilepsy? YES NO

What type of seizures do they usually have?

Tonic-Clonic Absence Other

If other, please give details:

On average, how frequent are they?

Hourly 2 hourly 4 hourly Daily Other

If other, please state how often:

On average, how long do they last?

Under 5 minutes 5-10 minutes Other

If other, please state how long:

Please state cause/s if known:

What action is generally taken when your child/young person has a seizure?

Does your child/young person have any allergies? YES NO

If yes, please list all known allergies:

Please describe the allergic reaction:

Any further information that you feel we should be aware of:

I give my consent to the following: (Please Tick)

Basic First Aid & Emergency Medical Attention:

I agree to my child/young person being given basic first aid by a trained first aider.

In the event of an emergency I agree to my child/young person being given any treatment, including general anaesthetic, which is felt necessary by a qualified medical or dental practitioner. I understand that reasonable efforts will be made to contact me as early as possible.

Photo/Video:

I agree to my child/young person being photographed (including video) whilst at the activities or events, and the photographs and video being used in publicity material produced by Shropshire Council such as leaflets, local newspapers and the Shropshire Council website.

Sharing of Information

I give consent for my child/young person to participate in the ‘All In’ Short Break activities and for their details to be shared within the Short Breaks project and providers of activities they attend unless I notify you otherwise in writing.

I give consent for Shropshire Council to request, obtain and share information for the child named above with relevant agencies when carrying out their functions regarding assessment, planning and commissioning as part of the Children and Families Act 2014. Relevant agencies may include but are not exclusive to:- social care, health, education providers, early years settings, pre and post 16 educational providers.

Please tick if you would like your child / young person to be put onto the Shropshire ‘Record of children with additional needs’ database

Please tick if your child is under the age of 5 and you would like us to share your child’s information with Children’s Centres Services so you may receive information that may be of interest to you

Declaration

I have read and understood this form and confirm that all of the information given is correct to the best of my knowledge

YOU NEED TO ADVISE US IF ANY DETAILS DECLARED ON THIS FORM CHANGE

SHROPSHIRE COUNCIL WILL USE THIS INFORMATION IN ACCORDANCE WITH THE DATA PROTECTION ACT 1998

Signature of Parent / Carer: ______

Print Name: ______Date: ______

How did you hear about ‘All In’? ______

Please send completed forms to: Family Information Service, Mount McKinley, Shrewsbury Business Park, Anchorage Avenue, Shrewsbury, Shropshire SY2 6FG. Telephone: 01743 254400. Email

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