Short Break Registration Form

YOU MUST FILL IN THIS FORM BEFORE YOUR CHILD/YOUNG PERSON CAN ATTEND OUR SESSIONS

Children's information for Short Break sessions

Registration Form
CONTACT US - If you need any assistance filling in this form
General Information
Which area will you be accessing?
Are you registering to attend one of our HAF sessions specifically?*
If yes, what is your HAF code?
What school does your young person attend?
What alternative provision does your young person attend?
Where did you hear about us?*
Does your child have a current EHCP. (Yes / No)
Have you accessed / access any other short breaks?
If yes please give details
Name of young person*
First Last
Name usually used
Date of birth*
Home Address - Please include postcode*
Telephone Number*
Mobile Number*
Email*
Parent / Carer name*
Who should we contact in an emergency?*
In the event we are unable to contact yourself and a medical intervention is needed, do you consent to us calling the emergency services? If no, please contact us to discuss before booking*
If no, please contact us to discuss before booking
About your child/young person
Please tell us any information that we need to be aware of about your child/ young person (eg. triggers, phobias etc.)*
Please summarise their additional need/ disability/ learning difficulty*
Please summarise any support they receive at home or in school – IF YOUR CHILD/ YOUNG PERSON REQUIRES ANY REGULATED ACTIVITY SUCH AS PERSONAL CARE OR MEDICATION ADMINISTRATION (INCLUDING RESCUE MEDICATION) Please contact us to discuss further before booking*
Any cultural or religious beliefs that we should know about:
Medical
Does your child have personal care requirements?*
If YES please expand on personal care needs and medication
Your child/young persons Doctor & surgery address*
Do you give us permission to contact them if nessessary?*
Is your child allergic to anything?*
If yes please give details
Do they need/carry an Epipen?
Communication
How does your child/ young person communicate?*
If speech – Does your child have any special words for certain things?*
Does your child/ young person use any Signs?*
If yes please give details
How will he/she communicate distress or dislike of something?*
Please summarise any negative, challenging behavior or distractions*
Does your child experience any seizures? If yes, please contact us before booking*
If yes, please contact us before booking
Personal Care
Please summarise any support they receive at home or in school – IF YOUR CHILD/ YOUNG PERSON REQUIRES ANY REGULATED ACTIVITY SUCH AS PERSONAL CARE OR MEDICATION ADMINISTRATION (INCLUDING RESCUE MEDICATION) Please contact us to discuss further before booking*
Does he/she signal in any way when needing to use the toilet?
Please summarise any mobility issues
Other Information
Is your child subject to a child protection plan/ a looked after child?
If yes, please give details including relevant custodial orders.
Is there anything else that we should know?
I/We* give permission for my young person to partake in planned group trips and activities with our team outside of the venue and in the local area (these will include trips to the park, scavenger hunts etc.)*
I understand that I need to send my young person to the session with a drink and where sessions run over meal times with a packed lunch unless otherwise stated*
Signature*
Printed Name
Date
DD slash MM slash YYYY
CONSENT FOR PHOTOGRAPHS, VIDEO CLIPS AND INTERVIEWS ENDORPHINS GROUP
Name of young person*
I/We* give my/our* full consent for the Endorphins Group to use photographs and video clips taken of me/ourselves* and/or my/our* words taken in interview, to be used for promotional and information purposes.
This will include using images, videos or quotes on our social media channels including - Facebook, Twitter, Instagram, Youtube & LinkedIn.
I/We* understand that my/our* photograph(s) and / or my/our* words may be used in various print or other media, locally or nationally, to promote and inform people about our activities.
I/We* understand that my/our* details, photograph(s) and / or my/our* words may be shared with our funding local authorities.
Print full name*
Signature
Date
DD dash MM dash YYYY
Thank you very much for helping us to inform people about our services
The personal information you have provided will help us to develop and deliver our services whilst enabling us to share it with our funding partners so we can adhere to contractual agreements. By signing the consent form below, you’ve indicated that you have read and agree to our privacy policy.

Short Break Registration Form

Registration Form

General Information

About your child/young person

Medical

Communication

Personal Care

Other Information

CONSENT FOR PHOTOGRAPHS, VIDEO CLIPS AND INTERVIEWS ENDORPHINS GROUP

Thank you very much for helping us to inform people about our services