Search @Shortbreakswal facebook – group – Short Breaks Walsall

Full name of child:
Gender (delete as appropriate): / Male / Female
Address(including Postcode):
Child’s date of birth:
Home telephone numbers:
Mobile numbers:
Emails:

School / College that the child / young person attends:

Ethnic Origin:

Bangladeshi
Black African
Black Caribbean
Black Other
Chinese
Pakistani
Indian
White British
White European
Other
Name of Parent / Carer:
Relationship to child (e.g. mother, father, step-parent, etc):
Name and relationship of Main Contact (if different from above):
Address of Main Contact (if not Parent or Carer):
Contact Number of Main Contact (if not Parent or Carer):
GP name:
GP address:
GP contact number:

To register your child we need a broad idea of what sort of disability they have. Please tick ALL boxes that apply to them:

Diagnosis (if any) Please enter more than one if necessary:

Moderate Physical Disability:

Child has limited function of two or more limbs and is partly dependent on others or equipment/aids for mobility and tasks such as dressing, feeding,toileting.

Severe Physical Disability:

Child has no use of function of two or more limbs or has no means of independent mobility at an age when their peers are independently mobile or fully dependent on others for daily living tasks such as dressing, feeding, toileting themselves.

If your child needs wheelchair, please tick box
Moderate Visual Impairment:

Registered partially sighted. Visual field may be restricted. May require special teaching materials.

Severe Visual Impairment:

Registered blind.

Moderate Hearing Impairment:

Hearing loss at least 40dB in one ear and same or worse in the other ear (but not greater than 60dB in either ear). Needs hearing aid, special equipment and Advisory Teacher.

Severe Hearing Impairment:

Hearing loss greater than 60dB (but not greater than 80dB) in better ear. Needs aids, special unit/Advisory Teacher and special equipment.

Profound Hearing Impairment:

Hearing loss greater than 80dB in better ear. Requires hearing aids, special unit/Advisory Teacher and special equipment.

Moderate Learning Disability:

Child needs extra help and support in some areas because of their learning difficulties. May be in mainstream school and require extra educational input. Will require modified curriculum and so mean adult support in daily living.

Severe Learning Disability:

Child is very dependent on others for his/her care because of their learning difficulties. Will require significantly modified curriculum at school, unaware of common dangers and more or less totally dependent.

Severe Communication Difficulties:

Child has significant difficulty communicating with others because of speech OR language problems. May require alternative communication.

Severe Behavioural / Emotional Difficulties:

Child has frequent aggressive/destructive episodes, is severely withdrawn or self-injurious. Behaviour adversely affecting schooling, peer group and home life. Behaviour is not due to a psychotic illness. Child requires outside help.

Psychotic Illness:

Child has a diagnosed psychiatric condition e.g. Schizophrenia, severe depressive illness or other psychosis, which makes them dependent on others in some areas.

Chronic Physical Health Problems:

Child has a long-term health problem which makes them dependent on others in some areas e.g. cystic fibrosis, severe epilepsy, sickle cell anaemia. May need on-site nursing care at school. Likely to have special educational needs as a result of ill health.

Autistic Spectrum Disorder:

Moderate / Severe

ADD / ADHD:

Moderate / Severe

Other e.g. dyspraxia, Tourette’s Syndrome (please specify):

Any other relevant details:

Does your child need help in the following areas:

Bathing / Continence / Dressing
Feeding / Personal Care / Toileting

Does your child have epilepsy?

Yes / No

Name and address of Health Professional (not your GP) who gave diagnosis. We may want to contact them about your child’s disability:

If appropriate, you may want to discuss the registration with your child. If you do, it would be useful to record their views below:

Signed: ______Parent / Carer

Print Name: ______Date: ______

How will we keep your information safe?

Any information you give on this form about yourself and your family will be kept in accordance with the Data

Protection Act 1998.Data will be kept on a secure database that can only be accessed by Walsall Children’s Services staff.

If you would like to see what information is kept about your family please telephone 01922 654634. There is a process to follow and they will help you. We may ask research organisations to undertake surveys for us. These organisations will be required to store the data securely and only use it for the agreed purposes.

If you do not wish to take part in any research, please tick the box to opt out□