Doc Code: CS/F23

Issue No: 9

Issue Date: Jan 2016

Children & Young People’s Services Activity Questionnaire

Confidential

General Details:

Childs Name:
Age: / D.O.B: / Weight:
Address:
Postcode:
Email:
Name of Parent/Carer: / Relationship to child/ young person:
Phone Number: / Mobile Number:

Additional Contact No (in the event of an emergency)

Name of Parent/Carer: / Relationship to child/ young person:
Phone Number: / Mobile Number:

It is essential that parents/carers are contactable at all times during activities.

At Cedar we have a duty to ensure children/ young peoples safety. Therefore we would ask that you give us details of people who can lift/ pick up children from activities and events:

Name: / Relationship to child/ young person:
Name: / Relationship to child/ young person:
Name: / Relationship to child/ young person:

CEDAR STAFF WILL NOT LET CHILDREN/ YOUNG PEOPLE BE COLLECTED BY ANYONE ELSE UNLESS PRIOR ARRANGEMENTS ARE MADE WITH STAFF

Please give details of your child’s disability.

Diagnosis:

Further details of your child’s support needs:

Social (Ability to mix with peers, Interests and hobbies, Awareness of social cues)

Physical (Mobility, Ability to take part in activities)

Communication (Sight, Hearing, Speech)

Does your child have any other specific health problems? Yes No

If yes, please give details.

Does your child have an awareness of personal safety?

(E.G. road awareness, sense of danger) Yes No

If no, please give details, including level of support needed

Does your child require assistance? Please give as much detail as possible. (E.G. what can your child do independently, what do they require help with). Complete form CSF058 if intimate care is to be provided by staff

Assistance with Toileting?

Dressing /Undressing?

Assistance with Eating?

Assistance with Mobility?

Please tell us about your child’s ability to move (e.g. do they require assistance when walking; does s/he use an aid e.g. a wheelchair or a rollator?)

If your child uses a wheelchair is it: Manual Electric

Is your child able to transfer independently? Yes No

If NO do they need specialist equipment e.g. hoist/banana board? (Please detail below)

Does your child have any special dietary needs?

Does your child have any behavioural issues? Yes No

E.G. verbal or physical aggression, destructive or disruptive behaviours, stereotypic behaviours (If yes please complete form CSF03 with staff)

Medical Details

1) Is your child on medication? Yes No

If answered YES to the above question please give further details (i.e name of medication, dose, amount, side effects, etc)

Name / Dose / Purpose of Medication / Side Effects?

If medication is required during activities please complete form CSF058 and CSF062 with staff

2) Does your child have epilepsy? Yes No

When did their most recent seizure occur:

If answered YES to the above question please complete form CSF07 with Cedar Staff

3) Does your child have any allergies? (E.G. Elastoplasts, nuts, suntan lotion or animal hair).

Yes No

If yes please give details (Type of reaction, any medical emergency triggered and treatment)

If allergic reaction triggers medical emergency please complete form CSF052 with Cedar Staff

4) Does your child have asthma?

Yes No

If yes please answer below:

Are there any triggers to an asthma attack?

How is it treated (medication, rest etc)

Water Based Activity

Swimming ability and experience:
I Parent/Carer give permission for to participate in water based activities and accept that my child is competent to do so with support as identified above.
Signed: ______(Parent/Carer) Date: ______

Please let us know what you would like for your child from the service (Include specific activities or programmes you would like to see offered)

Please use this space to let us know of anything else important

Consent (PLEASE READ CAREFULLY)

The Cedar Foundation sometimes uses children’s photographs for publicity purposes. Parents’ permission is sought for The Cedar Foundation to use photographs in this way.

Parental /Carers Consent

1. I give permission for pictures/ recorded imagery/ video of my Son/Daughter participating in Cedar Foundation Activities to be passed to local papers

2. I give permission for pictures/ recorded imagery/ video of my Son/Daughter

to be used in Cedar Foundation literature and publicity, including website

I give permission for my child to attend The Cedar Foundation Children and Young Peoples Services Activity Programme.

I also give permission to allow my son/daughter to use transport that will be organised by Cedar when applicable for activities and for young people to be given support with care needs as identified in this form.

I agree to inform staff of my child attending an activity and understand that Cedar will not be able to facilitate a place for my child without prior booking.

THE CEDAR FOUNDATION CANNOT BE HELD RESPONSIBLE FOR SPORT RELATED INJURIES THAT MAY TAKE PLACE DURING SPORTS ACTIVITIES.

I have read and agree with the above statements.

Signature ______(Parent)

Signature ______(Young Person)

Date ______

PLEASE HELP US BY RETURNING THIS FORM AS SOON AS POSSIBLE TO YOUR CLOSEST CEDAR OFFICE:

Western Area
The Cedar Foundation
Children and Young Peoples Services
Unit D3,
Balliniska Business Park,
Springtown Drive,
Derry /Londonderry
BT48 0NA / Southern Area
The Cedar Foundation
Children and Young Peoples Services
Suite 4 A'Tek building
Edenaveys Industrial Estate
Newry Road
Armagh
BT60 1EN / Eastern & Northern Area
The Cedar Foundation
Children and Young Peoples Services
1 Ravenhill Reach Close
Ormeau Embankment
Belfast
BT6 8RB

OFFICE USE ONLY

Identified Risks following Assessment

Type of Risk / Level of Risk
Low/Med/High / Action
Control Measures / Date
Physical (e.g. Mobility, Personal Care)
Medical e.g.
·  Seizures
·  Shunt
·  Epilepsy
·  Allergy
Behavioural/Emotional
Sensory
Awareness of Personal Safety
ASD
Other

Page 7 of 7