Summer Playschemes Preference Form 2017

Summer Playschemes – Preference Form 2017

Please complete all sections as fully as possible and please print clearly

Name of Child / Young Person:
Date of Birth:
Does your child require medication (whilst attending playscheme)? / Yes □ No □ (please √)
Does your child already have an up to date Care Plan with Home Based Breaks, Star House or Wasdale? / Yes □ No □ (please √)
If yes, then you do not have to complete all of the attached “All About Me”.
Please attach a copy of the existing Care Plan to this form and read/sign the consents in the “All About Me” only (last 3 pages).

Please return this form to:

SEND Development Team

Room 229,

County Hall

Bond Street

Wakefield

WF1 2QW

If you wish you can scan and email the signed forms to by 11 June 2017. We will acknowledge receipt of your email.

Please Turn Over

Please number up to 3 options, in order of preference.

Number 1 is your preferred Play Scheme.

Week / Date / Age / Provider / Preference (e.g. 1,2,3)
1 / 24th July –
28th July / 14 – 17 years / Pennine Camphill Community
5 – 11 and
12 – 16 years / Sportworks
5 – 10 and
11 - 17 years / Stride
2 / 31st July –
4th August / 5 – 8 and
9 – 12 years / KIDS Wakefield
5 – 11 and
12 – 16 years / Sportworks
5 – 8 and
9 – 12 years / Old Quarry Adventure Playground
12 - 17 years / WF Youth!
3 / 7th August –
11th August / 5 – 17 years / Horse Riding Group A
5 – 8 and
9 – 12 years / KIDS Wakefield
5 – 8 and
9 – 12 years / Old Quarry Adventure Playground
12 - 17 year / WF Youth!
4 / 14th August –
18th August / 5 – 17 years / Horse Riding Group A
5 – 8 and
9 – 12 years / KIDS Wakefield
5 – 8 and
9 – 12 years / Old Quarry Adventure Playground
5 – 11 and
12 – 16 years / Sportworks
5 / 21st August –
25th August / 5 – 17 years / Horse Riding Group B
5 – 8 and
9 – 12 years / KIDS Wakefield
5 – 8 and
9 – 12 years / Old Quarry Adventure Playground
5 – 11 and
12 – 16 years / Sportworks
6 / 28th August –
1st September / 5 – 17 years / Horse Riding Group B

Signed: ______(Parent/Carer)

Print name: ______(Parent/Carer)

Date: ______

2017 Summer Play Scheme

‘All About Me’

This Booklet is to help the staff at the play scheme understand you and get to know about what you like, dislike and what sort of help you may need.

Hello, my name is:…………………………………………………………………….

My birthday is on:…………………………………………………………………….

Please provide a photo to stick here

My Parents /Carers are called:………………………………………………………..

Other people who might collect me or drop me off at Play scheme are:

…………………………………………………………………………………………….

My emergency contact is called: ………………………………………………………

Phone number:…………………………………………………………

I live at:………………………………………………………………………………..…

……………………………………………………………………………………………

The important stuff about me!

My cultural/ religious background is:……………………………………

What languages I/my family speak:………………………………………………..

I have a condition/s called:……………………………………………………….…

……………………………………………………………………………………………………………………………………………………………………………………….…

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

My GP (doctor) is called:…………………………………………………

Phone number:……………………………………………………….……

I take medication Yes ¨ No ¨

This is what I take:……………………………………………………………………..

……………………………………………………………………………………………..

……………………………………………………………………………………………..…………………………………………………………………………………………..…

When I take it:

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

How I take it: eg. syringe, spoon, or other

I also take emergency medication for:……………………………………………

(Please tell us your consultant’s name and or nurse so that we can ask them more and arrange training and a health care plan. This is so people required to give emergency medication have been trained)

I am allergic to:………………………………………………………………………….

This is what happens if I have a reaction: ………………………………………...

I need you to do this if it happens: …………………………….……………………

…………………………………………………………………………….………………

Enjoying myself

My favourite toys, games, activities and interests are:

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

…………………………………………………………………………………………………

To take part in activities I need help with: ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………

These are some of the things that fascinate me or I can’t resist:

…………………………………………………………………………………………………

These are some things that I really don’t like:

…………………………………………………………………………………………………

Feeling Safe

I do / do not always understand that some things and certain situations could be dangerous. (Please cross out which does not apply, give further information below)

…………………………………………………………………………………….………………………………………………………………………………………..………………………………………………………………………………………………………..………………..

For me to feel safe I need:

………………………………………………………………………..………………………………….………………………………………………………………………….………………

……………………………………………………………………………..……………………

The staff will need to have the following training: (e.g. equipment, emergency medication etc.) to keep me safe:

I get around outdoors by:…………………………….……………………..………………

This is how to keep me safe when I’m going out:

I get around indoors by: ………………………………..…………………………..………

This is how to keep me safe indoors:……………………………………………...………

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….………….

I need the following support with dressing / toileting:

This is how I get on with other children and adults:

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

Communication

I will communicate with you by:……………………………………………………….……

……………………………………………………………………………………..…….……

…………………………….………………………………………………….…….…………

Please approach me like this:…………………………………………………..………….

Please speak to me like this:………………………………….……………….……………

………………………………………………………………………………………………………………………………………………………………………………………….…………

This is how I tell you how I feel

This is how I tell you I’m happy:……………………………………………….…………….

……………………………………………………………………………..…………………………………………………………………………………………………………..…………..

……………………………………………………………………………..………………

Some things that make me happy are:…………………………………………………….

……………………………………………………………………………..……………………………………………………………………………………………………………..

This is how I tell you I’m frightened or anxious:…………………………………………....

Things that make me frightened or anxious are:………………………………..…………

This is how I tell you I’m upset or cross:

This is how I will let you know that I’m hungry or thirsty:

……………………………………………………………………………..………………………………………………………………………………………………………….…………….

This is how I will let you know I’m not well or in pain:

……………………………………………………………………………..………………………………………………………………………………………………………….…

This is how I will let you know I want to go to the toilet or please change my pad:

……………………………………………………………………………..………………

…………………………………………………………………………………….………

Food and Drink

My favourite snacks/drinks are:

I like the texture of my food to be:

I like the temperature of my food to be:

I don’t like these foods/drinks:

……………………………………………………………………………..………………………………………………………………………………………………………….….

I eat and drink using: (spoon, fork, built up dish, special cup)

I need the following help to eat and drink:

I do not eat or drink orally /or in addition to my diet I have a gastrostomy, NG tube /or I require dietary supplements:

……………………………………………………………………………..………………………………………………………………………………………………………….………………………………………………………………………………..………………………………………………………………………………………………………….…

I am not allowed to have any of the following foods/drinks:

Why? What happens if I do?

Other things I would like you to know:

Contacts

People you might need to contact about training and or equipment I might require (Therapist, GP, Social Worker, Children’s Community Nurse, School)

I agree for you to contact them Yes ¨ No ¨

Name / Role / Telephone number

Play scheme 2017 Consent Statement

Wakefield Council’s Children & Young People Directorate deals with personal data under the Data Protection Act 1998. Some of these may be sensitive, such as health, ethnic origin or religious beliefs. We share some or all of them with other council departments, Service Providers or other third parties. When involving any third party we shall take all reasonable steps to ensure that they will keep your personal data secure and treat it confidentially. If you are worried about giving us personal details or about sharing them with others, please discuss this with a staff member who will explain what to do.

This consent statement is addressed to the child or young person. In many cases a parent or carer may need to sign on the child’s behalf, or in addition to the child. Please therefore read ‘you’ as meaning ‘your child’ if you are the parent or carer.

Play Scheme is asking you to consent to the following:

1. For Play Scheme to store your personal information, such as your address, what medication you receive, and all the other information that you give us. To safely work with disabled children, young people and their families, Play Scheme has to store personal information about you. Without your agreement to this, Play Scheme cannot work with you.

2. In the event of an emergency for Play Scheme to take appropriate action, if necessary administer first aid, call the emergency services, and contact the people listed on the front of this form. You must agree to this if you are going to be in Play Scheme care without your parent/carer.

3. For Play Scheme to share your personal information only if we need to. You do NOT have to agree to this. However, to meet your needs Play Scheme may want additional advice or support from other professionals, such as speech & language therapists, educational psychologists, health visitors etc. With some Play Scheme services, if you do not agree to this it will reduce the support that Play Scheme can give you.

4. For Play Scheme to take, and use photographs and/or video of you for publicity purposes. You do NOT have to agree to this. However if you do not agree, you may be asked to sit out of an activity for a short time while other young people are being photographed or videoed. This time will be kept to a minimum.

5. For Play Scheme staff to administer medication and/or carry out the medical procedures identified on this form. You do NOT have to agree to this. If you do not agree, the medication and medical procedures section of this form should not be completed.

6. For Play Scheme staff to provide intimate personal care identified on this form. You do NOT have to agree to this. If you do not agree, please be careful to only complete the items in the personal care section of this form that you are happy for Play Scheme to staff to do.

7. For Play Scheme staff to apply sun cream and/or oil for massage purposes. You do NOT have to agree to this.

8. For Play Scheme staff to engage you in face painting. You do NOT have to agree to this.

Consent by Parent/ Carer and or Child/ Young Person

A parent or carer must sign this form if the child is aged 11 or younger, or if the child or young person is aged 12 or above, but has learning difficulties and/or cannot understand it. Children and young people aged 12 or above must sign this form if they are able to understand it.

If both child/young person and parent/carer are signing, they should agree to the same consents between them.

Consent by young person

Please circle as appropriate

1. I agree to Play Scheme storing my personal information

YES/NO (must be ‘YES’ to attend the Play Scheme)

2. I agree that in an emergency, Play Scheme will take appropriate action YES/NO (must be YES if no parent/carer will be present)

3. I agree to Play Scheme sharing my personal information with other professionals, as necessary

YES/NO

4. I agree to Play Scheme taking and using photographs and/or video of me for publicity YES/NO

5. I agree to Play Scheme staff administering medication/medical procedures to me, as identified on my All About Me

YES/NO

6. I agree to Play Scheme staff providing intimate personal care to me, as identified on my All About Me

YES/NO

7. I agree to Play Scheme staff applying sun cream to me

YES/NO

8. I agree to Play Scheme staff applying oil (for massage) to me (when I choose this)

YES/NO

9. I agree to have my face painted (when I choose this)

YES/NO

10. I agree to keeping Play Scheme staff informed of any changes to the information on this form YES/NO (While I use Play Scheme services this must be ‘YES’)

Signature of child or young person aged 12 or above

……………………………………………….…………………………….. Date……….……………

Consent by Parent or Carer

Please circle as appropriate

1. I agree to Play Scheme storing my child’s personal information

YES/NO (must be ‘YES’ to attend the Play Scheme)

2. I agree that in an emergency, Play Scheme will take appropriate action YES/NO (must be YES if no parent/carer will be present)

3. I agree to Play Scheme sharing my child’s personal information with other professionals, as necessary

YES/NO

4. I agree to Play Scheme taking and using photographs and/or video of my child for publicity YES/NO

5. I agree to Play Scheme staff administering medication/medical procedures to my child, as identified on my child’s All About Me

YES/NO

6. I agree to Play Scheme staff providing intimate personal care to my child, as identified on my child’s All About Me

YES/NO

7. I agree to Play Scheme staff applying sun cream to my child

YES/NO

8. I agree to Play Scheme staff applying oil (for massage) to my child

YES/NO

9. I agree to have my child’s face painted

YES/NO

10. I agree to keeping Play Scheme staff informed of any changes to the information on this form YES/NO While your child uses Play Scheme services (this must be ‘YES’)

Signature of parent or carer of child

……………………………….…………………….………………………………..Date………………