APPLICATION TO ATTEND YOUR SPACE

Your Space is an activity and social club for young people and children with a diagnosis of an Autistic Spectrum Disorder and/or related condition, providing out of school activities for those age 5-19.

On offer will be various opportunities to become involved in creative arts, music, dance, drama, outdoor pursuits, sports, discussion groups, sensory and free play as well as the opportunity to enjoy socialising and personal development.

Each child/young person referred is assessed on an individual basis to suit their specific needs.

CHILD/YOUNG PERSON’S FULL DETAILS
Full Name
Gender / Male / Female
Date of Birth
Address
Postcode
Home Tel No / Mobile No
Email
1st Emergency
Contact / Mobile No
2nd Emergency Contact / Mobile No
What is the nature of the child/young person’s disability? Eg Asperger’s or ASD and/or other related conditions.
Who is the main carer?
Do they have parental responsibility? / Yes / No
If no, please provide details
Other members of the household
Full Name / Relationship
Name of Social Worker (if applicable)
Address
Tel No
School
Address
Tel No:
Teacher’s Name
Does s/he have 1-1 support in school? / Yes / No
Is s/he in a supported unit within school? / Yes / No
Does s/he receive Disability Living Allowance? / Yes / No
Does s/he have a Statement of Special Educational Needs? / Yes / No
DAILY CARE
Staffing requirements (eg 1-1 worker when out of building, 2-1 worker required for personal care, functions well in a small group etc)
Any specific additional information which will aid us in supporting him/her in the most appropriate way: eg Does s/he have any sensory issues? (noise levels, smells, tastes, PICA, hypo/hyper sensitivity).
Obsessions, interest, diversion techniques?
Does s/he exhibit behaviours that may be challenging/difficult behaviours and does this cause risk to self and others?
Yes / No
If yes, how?
Does s/he have a tendency to wander or try to run away?
Does s/he have awareness of danger? (eg road safety)
Does s/he have a fear of the outside environment or specific phobias? (eg dogs) How would you like us to assist in this area?
Does s/he experience any difficulties with moving?
Yes / No
MEDICAL INFORMATION
GP
Address
Tel No
Child/young person’s health needs and medical conditions
Does s/he have a diagnosis of epilepsy or have they ever experienced a seizure? / Yes / No
If the child/young person takes medication please list and provide protocol for administration.
Please note: You will be asked for further information once accepted into the group
Any additional information regarding health requirements (does s/he have any dietary requirements/allergies?
COMMUNICATION
First language
Does s/he communicate using speech? / Yes / No
Does s/he appear receptive to verbal language? / Yes / No
Does s/he appear expressive in use of verbal language? / Yes / No
Forms of communication used?
British sign language / PECS/visual / Makaton/BSL
Gestured communication / Timetable / Other
Additional information (preferred means of communication)
PERSONAL CARE NEEDS
Does s/he use the toilet? / Yes / No
Does s/he wear attends/pads? / Yes / No
Additional information (are they undergoing a training programme?)
OTHER
Does s/he attend any other out of school activities or groups? / Yes / No
Groups attended previously / Reason for leaving?
Does s/he have respite care? / Yes / No
If yes please give details.
Any additional information to support your application
(Please attach a photo if possible)
Name of person making the referral
Relationship to referral/position held
Address
Tel No
Signature / Date
Signature of Parent/Carer / Date
Where did you hear about Your Space
Social Worker / School / Friend
Press / Internet / GP/Health Worker
Voluntary Group / Other (Please give details)

EQUALITIES MONITORING

In order to endure that our service is accessible to all children and young people with an Autistic Spectrum Diagnosis and/or related condition, please complete this form by ticking the boxes which apply. The information you provide on this form will be kept separate from the referral form and treated in the strictest of confidence. All information will be used for statistical purposes only.

To which age group does the child/young person belong?
8-10 / 11-13
14-16 / 17-19
What is his/her ethnic origin?
White British / Asian/Asian British / Chinese
White Welsh / Bangladeshi / Mixed Race Caribbean
White English / Indian / Mixed Race White African
White Scottish / Pakistani / Mixed Race Black African
White Irish / Other Asian / Non Defined
White Other (please define) / Black/Black British / Caribbean
African
What is his/her first language?
Welsh / English / British Sign Language
Other (please state)
Do not wish to disclose

INDIVIDUAL PERSON PROFILE

PERSONAL DETAILS
Date
Name
Date of Birth / Age
Interests
Strengths/abilities
Likes
Dislikes
Friendships
No Support Needed / Limited Support Needed / Moderate Level of Support Needed / High Level of Support Needed / 1:1 Support Needed
Communication and interpretation
Personal mobility and transport
Health issues and medication administration
Violent and/or challenging behaviours
Personal care and hygiene
Eating and drinking
PLEASE WRITE SERVICE USER SPECIFIC NEEDS BELOW
Communication & Interpretation
Personal Mobility & Transport
Health Issues & Medication Administration
Violent and/or Challenging Behaviours
Personal Care & Hygiene
Eating & Drinking
Name of person completing profile:
Signed:
Dated:
Date of Next Review:

PHOTOGRAPIC CONSENT FORM

Dear Parent/Carer,

During our sessions at Your Space we like to take photographs/videos of children taking part in activities to show progression and for future event publicity. All photographs are kept securely and will not be distributed to third parties, without your consent. They may be used to assist in publicity for Your Space and may appear on our Website and Facebook page.

Please delete as appropriate.

I would/ would not like my child ……………………………………………………. To have their photograph taken during Your Space sessions.

Signed:
Print Name:
Date:

Yours faithfully

Rachel Hancocks

Your Space Co-Ordinator

INTERNET ACCESS CONSENT FORM

Parent’s consent for Internet Access

I have read and understand the Your Space rules for responsible Internet use and give permission for my son / daughter to access the Internet. I understand that Your Space will take all reasonable precautions to ensure participants cannot access inappropriate materials. I understand that Your Space cannot be held responsible for the nature or content of any materials accessed through the Internet. I agree that Your Space is not liable for any damages arising from use of the Internet facilities.

Signed:
Print Name:
Date:

Your Space, Gwersyllt Resource Centre, Second Avenue Gwersyllt, Wrexham LL11 4ED

Tel: 01978 756804

Email:

Website: wwwyourspacemarches.co.uk

Registered Charity Number: 1153848 Company no: 8377544