Luton’s children with disabilities register form

Luton Council is required by the Children Act 1989 to keep a register of children with disabilities living in Luton. By registering your child you will be providing us with information on the needs of your child and your family to enable us to plan for the future and improve the quality of life for children with disabilities living in Luton.

Please complete all sections and questions on this form

About the child or young person

First Name
Middle name/s
Last name
NHS number*
Full Address
including postcode
Please include a colour photo of a similar size.
Date of Birth
Gender / Male / Female / Prefer not to say

*you can get your child’s NHS number from your GP.

Ethnic origin of the child or young person – please choose one option

Asian or Asian British /  / Bangladeshi /  / Indian
 / Kashmiri /  / Pakistani
 / Other (Please state)
Black or Black British /  / African /  / Caribbean
 / Other (Please state)
Mixed / Multiple ethnic group /  / White and Asian /  / White and Black African
 / White and Black Caribbean
 / Other (Please state)
White /  / British /  / Irish
 / Gypsy /  / Traveller or Irish Heritage
 / Other (Please state)
Other ethnic groups or
Prefer not to say /  / Chinese /  / Prefer not to say
 / Other: (Please state)

About the parent / carer

Title / Mr / Mrs / Miss / Ms / Other please state
Name:
Full Address:
If different from above
Preferred contact number:
Alternative contact number:
Email address:

Impact on daily life:

Please rate the impact of your child/young person’s disability or additional need on their day to day life in the following areas.

Area / Low impact / Medium impact / High impact / None or Not applicable
Communication – behaviour/interpersonal/social skills / £ /  /  / 
Communication – speech and language /  /  /  / 
Developmental delay /  /  /  / 
Hand function /  /  /  / 
Health – chronic long term illness /  /  /  / 
Hearing /  /  /  / 
Learning disability /  /  /  / 
Mobility /  /  /  / 
Personal care – continence /  /  /  / 
Personal care – eating/drinking /  /  /  / 
Personal care – washing/dressing /  /  /  / 
Vision /  /  /  / 

Please tick all boxes applicable to your child; if your child’s condition/diagnosis is not shown in the list below please use the ‘Other’ box to provide details.

Disabilities / Health
 / Aspergers Syndrome /  / Allergies / Anaphylaxis
 / Autistic Spectrum Conditions /  / Asthma
 / Cerebral Palsy /  / Diabetes
 / Downs Syndrome /  / Epilepsy
 / Genetic Disability /  / Gastrostomy
 / Global Development Delay /  / Personal Care
 / Hearing Impairment /  / Tracheotomy
 / Learning Disability /  / Nasogastric feeds
 / Physical Impairment /  / O2 dependent
 / Visual Impairment
Additional Needs / Assessment of educational needs
 / ADHD /  / Early Help Assessment (EHA)
 / Behaviour that challenges /  / Education, Health and Care Plan (EHC)
 / Communication difficulties /  / Learning Difficulty Assessment (LDA)
 / Dyslexia / dyspraxia /  / Statement of Special Educational Need
 / Emotional behaviour difficulties /  / None of these
 / Learning Difficulties
 / Sensory Difficulties
Please provide more detail about your child’s condition including any dates of medical diagnosis
Continue on a separate sheet if necessary


Professional contacts:

Please mark who your child/young person already has contact with:

 / Advisory teacher (SEN) /  / Occupational therapist
 / Child and adolescent mental health service /  / Paediatrician / consultant
 / Community Nurse /  / Physiotherapist
 / Educational psychologist /  / Social worker
 / GP (registered with a Luton GP) /  / Special needs health visitor
 / Health visitor /  / Speech and language therapist
Please list any other professionals your child/young person has contact with. Continue on a separate sheet if necessary
Does your child currently attend a childcare or education setting?
e.g. a nursery, pre school, childminder or a school / Yes / No
If yes which setting/s do they attend

Support services

Please tick if you would us to send you information on any of the following services – please note that some of these services will depend on eligibility criteria being met.

Childcare and Activities / Support Services and information
 / After school care /  / Blue Badge scheme
 / Childminders /  / Education, Health and Care plans
 / Early Years setting e.g. nurseries /  / National Key Scheme (disabled toilets)
 / School holiday activities /  / Parenting courses
 / Short break services /  / Transport to school

Family Information Service (FIS) are here to help parent/carers by providing information and advice or signposting families to the most appropriate information that may be useful to them. If you have any questions please write them below and we will do our best to help you.

Confidentiality

The information that you have given will be treated as confidential, and may be shared with other Luton Council departments to help support you and your child. Information used for planning future services will be anonymous numerical information and will not identify individuals. The information held on the Luton’s children with disabilities register is held in compliance with the Data Protection Act 1998.

If you have given us your email address you will be subscribed to our e-newsletter Enabled; this publication has information on services, support and activities for families with children with additional needs or disabilities. If you would prefer not to be subscribed to the e-newsletter please tick this box 

Signature of parent /carer:
Date:

Please return this form to:

Laura Armstrong

Flying Start Office, 2nd Floor TOKKO, Gordon Street, Luton, LU1 2QP

Tel: 01582 548888 Email: Web: http://directory.luton.gov.uk/send