Secondary Years Family Day

SECONDARY YEARS FAMILY DAY

BOOKING FORM

Saturday 12TH November 2016

Thornhill Church Centre, Excalibur Drive, Cardiff, CF14 9GA

First Name………..……………………………………………………………………………

Surname……………………………………………………......

Relationship to Child:

Parent

Carer

Grandparent

Other

Address 1……………………………………………………………......

Address 2……………………………………………………………......

Town……………………………………………………………......

County……………………………………………………………......

Postcode …..………………………………………………………………………………

Telephone Number (preferably mobile telephone) ……………………………………..

Email (we email whenever possible to save on postage and trees)

………………………………………………………………………......

Please confirm your email address ………………………………………………………..

Are you a member of HemiHelp? (You do not need to be a member to attend the event)

YesNo

Other Adults Attending

Adult 2 First Name…………………………………………………………………………..

Adult 2 Surname.………………………………………………………......

Relationship to Child:

Parent

Carer

Grandparent

Other

Adult 3 First Name…………………………………………………………………………..

Adult 3 Surname.………………………………………………………......

Relationship to Child:

Parent

Carer

Grandparent

Other

Adult 4 First Name…………………………………………………………………………..

Adult 4 Surname.………………………………………………………......

Relationship to Child:

Parent

Carer

Grandparent

Other

About You

To help us monitor the effectiveness of our events, please answer the following questions. This information is used when applying to Trusts for essential funding of HemiHelp services.

Is this the first HemiHelp event you have attended?

YesNo

KNOWLEDGE – Please rate each question from 1-5

Before attending the event, how much do you know about the physical and learning barriers that can arise for children with hemiplegia during Secondary School?

1 – Nothing

2 – Minimal knowledge

3 – Basic knowledge

4 – Good knowledge

5 – Excellent knowledge

(Please go to Page 3)

Before attending the event, how much do you know about the issues your child with hemiplegia might face as they move on to become a more independent teenager?

1 – Nothing

2 – Minimal knowledge

3 – Basic knowledge

4 – Good knowledge

5 – Excellent knowledge

CONFIDENCE

Before attending the event, how confident are you in working with the school to support your child through Secondary School?

Not confident at all

Somewhat confident

Fairly confident

Very confident

Extremely confident

WHAT DO YOU WANT TO GET OUT OF ATTENDING THIS EVENT?

Please rank from 1-5 how important the following are to you (1-5 where 1 is the LEAST important and 5 is the MOST important)

1 / 2 / 3 / 4 / 5
To gain knowledge about how you can help your child’s teachers understand their hemiplegia?
To gain knowledge about the benefits of physiotherapy for teenagers?
To find out more about supporting your child to become a more independent teenager?
To meet other families?

Media Consent

PHOTOGRAPHS HemiHelp may take photographs of you and your child participating in activities and use these in internally produced publications (e.g. our magazine, Annual Review, Posters) and/or on our website and social media channels (e.g. Facebook, Twitter, Flickr). As part of our aim to raise awareness of hemiplegia, they may also appear in other targeted print media (e.g. medical/educational publications, local and national newspapers) and approved online channels (e.g. websites/social media).

VIDEO HemiHelp also takes video footage at events to be used in our internally produced videos. These may appear on our website and social media channels (e.g. Facebook, Twitter, our YouTube channel). Please check the relevant box to state your preference on these issues.

YES I am happy for my family’s photographs or videos to be used as stated above.

NO I do NOT want my family’s photographs or videos used by HemiHelp

Other ………………………………………………………………………………………………………………………

Children attending this event

Child 1 - First Name (This should be your child with hemiplegia)

…………………………………………………………………………………

Child 1 – Surname …………………………………………………………………………………

Child 1 – Age…………………………………………………………………………………

Sibling or Friend

First Name…………………………………………………………………………………

Surname…………………………………………………………………………………

Age…………………………………………………………………………………

Health & Safety

Please detail below, any relevant medical conditions (apart from hemiplegia) and any medication your child(ren) may currently be taking (e.g. for epilepsy, asthma etc). If there is more than one child on this form, please state the name of the child you are referring to.

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

Please complete and return to

Samantha Lee, HemiHelp, 6 Market Road, London, N7 9PW