Application Form

Stuff U need 2 know about ...

- Social Situations

- Sex & Relationships

Application Process

·  The closing date for applications is Friday 1st November 2013

·  After the closing date all applications will be reviewed, and places will be confirmed as soon as possible.

·  Places are not guaranteed until confirmed by Autism Family Support.

How to complete the Application Form

By email

- Type in the shaded areas of the form (pages 2 and 3).

Handy Tip: You can use the Tab key on your keyboard to move to the next part of the form.

- Save the document.

- Email the form as an attachment to:


By post

- Complete the form using a black or dark blue pen.

- Post the form (to arrive by the closing date) to:
Workshops, Autism Family Support, Thomley Hall Centre, Menmarsh Road, Worminghall, HP18 9JZ

Enquiries

If you have any queries or wish this form to be posted to you, please contact:

Gita Lobo, Tel: 07929 379125 Email:

Please go to Page 2 for the Application Form ....

Application Form

Stuff u Need 2 Know About ...

- Social Situations

- Sex & Relationships

Please TYPE (in the shaded areas) OR WRITE clearly using black or blue ink

Name of Young Person:
Age: / Date of Birth: / Diagnosis:
Is s/he aware and accepting of diagnosis? Yes No
School/College:

Contact Person (Parent/Guardian)

Name: / Relationship to child:
Home Tel: / Mobile No:
Email Address:
Home/Correspondence Address (inc postcode):

EMERGENCY CONTACT. Please list TWO people who can be contacted in an emergency (if different from above). At least one mobile number is required.

1 / Name: / Relationship to Child:
Home Tel: / Mobile No:
2 / Name: / Relationship to Child:
Home Tel: / Mobile No:

Please tell us about the young person

What are your child’s particular interests/hobbies?
Please tell us of any medication or health issues (e.g. allergies, medication, asthma, epilepsy):
Will the medication need to be taken whilst the young person is attending the workshop? Yes No
If YES we will contact you and a medical form must be completed.
Please describe any communication difficulties the young person may have
Potential Risks
Does the young person abscond from settings or people (i.e. school, home, groups, etc)? Yes No
If YES please give details, and explain how staff should manage the situation if it arises:
Is the young person physically or verbally aggressive? Yes No
If YES please give details, and explain how staff should manage the situation if it arises:
Does the young person self-harm? Yes No
If YES please give details, and explain how staff should manage the situation if it arises:
Please describe any other challenging behaviour or difficulty the young person may experience:
Please list anything that may cause stress or fear, and how s/he expresses being stressed or scared:
Please list any other groups/activities the young person attends:

Is there any additional information we should be aware of?

Please ‘X’ boxes to provide consent Parental Agreement
Photographs
I give consent for photographs to be of taken of my son/daughter during the course to be used in funding applications and purposes for the development and publicity of Autism Family Support.
Any Comments:
Permission for Use of Physical Intervention
I consent for trained staff to use physical intervention with my child, and I understand that they will always use the least invasive technique for the minimum period of time and it will only be used when all other strategies and techniques have been attempted.
Medical Information
I agree to my son/daughter receiving any and all emergency medical treatment, including anesthetic and/or blood transfusion, as may be considered necessary by the medical authorities in attendance, should the need arise. I undertake to inform Autism Family Support of any change in my child’s medical circumstances.
Use of Data: These workshops are funded by Oxfordshire County Council (OCC).In order to assess the impact and coverage of the scheme,OCC require us tocollect information such asyour child’s name and date of birth. This information is used to ensure best possible service across the County. All information iskept in strict confidence andis not shared with otherorganisations. If you have any questions please contact us for more information.

Application Request

Date / Workshop / Please ‘X’ to apply
for a space / Official Use
23rd Nov / Social Situations
30th Nov / Sex & Relationships
7th Dec / Refresher day
Signed (or if emailed please ‘X’ ): / Name:
Relationship to child: / Date:

Please return this form by email to:
Or post to: Workshops, Autism Family Support, Thomley Hall Centre, Menmarsh Road, Worminghall, HP18 9JZ