Waikato Holiday Programme 2017
4. Child/Young Person Profile Form

Please complete one per year

Child/Young Person’s Profile
First Name: / Surname:
Gender: / Date of birth:
School:
Diagnosis:
(List all) / Year of Diagnosis:
Parent/Caregiver: / Phone:
Likes/interests:
Dislikes:
Dietary Requirements:
Swimming Ability:
Goals for child/young person on the Holiday Programme:
What level of support does the child/young person have at school?
Medical Information (for Child/Young Person)
Medical Centre: / Phone:
Name of child/young person’s Doctor:
Seizures: / Yes / No
Epilepsy: / Yes / No
Other medical conditions:
If yes to either seizures or epilepsy, please complete 5. Epilepsy/Seizures Treatment Consent Form.
Allergies: / Yes / No
If yes, what:
Treatment required:
Medication: / Yes / No
If medication is required, complete 6. Medical Consent Form.
Behaviours
(Please specify if your child/young person has any of the following behaviours)
Eating: / Independent / Needs some assistance / Needs full assistance
Drinking: / Independent / Needs some assistance / Needs full assistance
Toileting: / Independent / Needs some assistance / Needs full assistance
If yes, please explain:
Speech: / Verbal / Non-Verbal / Single words / Sign Language / PECS (Pictorial Education Communication System)
Note: If your child/young person uses PECS – please bring their PECS to the Programme.
Runner: / Yes / No
Climber: / Yes / No
Hider: / Yes / No
Physical behaviour towards self: / Yes / No
If yes, please explain:
Physical behaviour towards others: / Yes / No
Hit / Yes / No
Kick / Yes / No
Bite / Yes / No
Scratch / Yes / No
Touch / Yes / No
Pinch / Yes / No
Other (please specify):
If yes, please explain:
Behaviours, continued
Physical behaviour causing damage to equipment, activities or surroundings: / Yes / No
If yes, please explain:
Sexualised behaviour: / Yes / No
If yes, please explain:
Triggers and Prevention
(Please list behaviours and triggers, and also explain how to prevent and manage the behaviour)
Behaviour / Trigger / Prevention / Management
Other comments

Note – If any of the information you have provided on the child/young person profile form changes it is your responsibility to let the holiday programme coordinator know.

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