Play Adventures & Community Enrichment (PACE)
RegistrationForm
PleaseuseBLOCKCAPITALletters Playcentre/After School Club ______
SectionA
Childdetails
Surnameofchild First name/sofchild Date ofbirth: Day Month Year Male Female
Schoolattended?
Arethereanycourtordersactivein relation toyourchild?YesNo
Ifyes,wedorequireacopy whichwillbestoredconfidentially.
Wealsorequirethatyounotifyuspromptlyofanychangestosuchorders.
Parent/guardiandetails
Parent/guardian1
Fullname Relationship tochild Home address
Hometelno
Mobile telno
Work/studyaddress
Work telno WorkEmail
Doesthispersonhaveparentalresponsibility?
Yes No
Isthispersoncurrentlyworking?
Yes No
Ifyes,dotheywork? Lessthan 16hrs
Morethan 16hrs
Parent/guardian2
Fullname Relationship tochild Home address
Hometelno Mobile telno Email Work/studyaddress
Worktelno WorkEmail
Doesthispersonhaveparentalresponsibility?
Yes No
Isthispersoncurrentlyworking?
Yes No
Ifyes,dotheywork? Lessthan 16hrs
Morethan 16hrs
Otheradultswith permissiontocollectyourchild
Fullname Address
Relationshiptochild Home telno Mobiletelno
Fullname Address
Relationshiptochild Home telno Mobiletelno
Health/socialcarecontactdetails
ChildsGP Address
TelephoneNo
Otherhealth/socialcarecontacts,eg:SocialWorker/CommunityNurse
Name Role Address
TelephoneNo
SectionBHealth/Disability/PersonalNeeds
Name Role Address TelephoneNo
Pleaseanswerthefollowing10 questions,ifyouanswerYEStoanyquestionpleasecompleteaseparate Personal
NeedsFormas wemay requirefurtherinformation.Amemberofstaffwillsupportyoutocompletetheform,ifrequired.
Health/disability
Doesyourchildhavealongstandingillness,
medical conditionoris yourchilddisabled? Yes No
Medication
Doesyourchild require medication for
a long-standing illness? Yes No
Allergies
Doesyourchild have any allergies
(including sunblock)? Yes No
Eating/drinking
Doesyourchild require support with eating/
drinking (eg: use of special equipment or
dietary requirements)? Yes No
Personalcare
Doesyourchildrequire assistance
with personal care (eg: dressing/toilet)? Yes No
Mobility
Doesyourchild require assistance moving
around the playcentre or on trips, use a
wheelchair or mobility aid? Yes No
Communication
Doesyourchild require support with
communication systems (eg: PECS,
Makaton, BSL)? Yes No
Behaviour
Doesyourchild have behaviour
difficulties which you would like us
to recognise and support? Yes No
Culturalpractice
Doesyourchild uphold any cultural practice
which you would like us to recognise (eg:
holiday celebrations, dietary requirements)? Yes No
OtherPersonalNeeds
Doesyourchildhaveanyotherpersonal
oradditional needs? Yes No
SectionC Consent
Consentandsignatureofparent/guardian
•Iunderstandthequestionsontheformandhavegivenfullrepliestothem.IknowthatifIhaveansweredyestoany questionswithinSectionBImustfillin a‘PersonalNeedsform’.
•IconfirmthatIhaveparentalresponsibilityforthechildnamed in thisregistrationform.
•Intheeventofanypublicity/promotionin relation toPACE,Igive mypermissionforphotographsofmychild toappear.Thismay includePACEleaflets, newspapers,be partofan exhibition,oronaLB of Camden/partnerswebsite.
•Igive myconsentforsun blocktobeappliedonmychild.
•Igive myconsentforPACEtogather andshareinformationwithrelevantprofessionalgroupsin orderthatmychildreceivesasafeandappropriatelevelofcare.
•Igive myconsenttoanymedicaltreatmentnecessaryduringPACEactivities,andthereforeauthorise PACEstafftosign onmybehalf, anywrittenformofconsentrequiredbyhospital/medicalteams.Thisis providedeveryefforthasbeenmade toreachme, andthatdelayin treatmentis likelytoendangerthechild’shealthorsafety in theopinionofthedoctororhospital.
Signed(asproofofconsent) Relationship tochild Date
Consentforsupervisedoutings
Theplaycentresometimesorganisesoutings,travellingonpublictransportand/orhiredcoachesorminibuses (allhiredvehiclesarefittedwithseatbelts).Standard outingsinclude activitieslikeswimming,theatre,seaside excursions,cityfarmtrips,andvisitstoparksandplaygrounds.Wewouldletyouknowbeforehandifwewereplanning anyotheractivities.
Arethereanyactivitieslistedabove whichyoudonotwishyourchildtoparticipatein?YesNo
Pleasespecify I give myconsentformychildtoparticipatein activitieswiththeexemptionofthoselistedabove.
Signed(asproofofconsent) Relationship tochild Date
Consenttoleave/arriveatplayprovisionunaccompanied
Ifyouwantyourchildtoarriveand/orleavetheplaycentreunaccompanied,youmustprovidewrittenconsent. Children aged 8 andunder arenotpermittedtoarrive/orleavetheplayprojectunaccompanied.
Signed(asproofofconsent) Relationship tochild Date
Section D
Monitoring
PACE aims to provide access to all children. In order to ensure this, it is important to monitor who uses our services.
Please help us to gather this information by completing the form below.
Child’s gender / Male / / Female / Child’s age
Ethnic Origin: Please tick ()
Our ethnic background describes how we think of ourselves. Ethnic background is not the same as nationality or country of birth. The groups listed below reflect the largest ethnic groups in Camden.
White:
British
Irish
Greek or Greek Cypriot
Turkish or Turkish Cypriot
Albanian, excluding Kosovan
Kosovan
Any other White background,please specify ……………………………………………………………………
Asian or Asian British:
Indian
Pakistani
Bangladeshi
Any other Asian background, please specify …………………………………………………………………………
Chinese or other ethnic group:
Chinese
Any other group, please specify ………………………………………………………………………………………………………………………………………………………………… / Mixed:
White and Black Caribbean
White and Black African
White and Asian
Any other Mixed background,please specify …………………………………………………………………………
Black or Black British:
Congolese
Nigerian
Ghanian
Kenyan
Caribbean
Somali
Any other African background, please specify …….………..…………………………………………………………
Any other Black background, please specify ………..…………………………………………………………………
Please add your child’s country of birth:
……………………………………………………………………………………………………………………………………………………………………
Health and Disability
The Disability Discrimination Act (1995) defines a disabled person as someone who has a physical or mental impairment that has a substantial and long term adverse effect on his or her ability to carry out day to day activities.
Does your child have a longstanding illness, medical condition or disability? / Yes / / No / / Prefer not to say / If yes, please tick the boxes below that describe your child’s particular needs
Health or medical needs e.g. allergies, asthma
Cognitive or learning needs e.g. dyslexia, learning difficulties
Mental health difficulties e.g. anxiety, phobias
Sensory impairment e.g. hearing impairment, visual impairment
Speech language, communication or interaction needs and difficulties
Autistic spectrum disorder e.g. Asperger’s syndrome, autism
Physical needs and difficulties e.g. arthritis, cerebal palsy
Behaviour, emotion and social development needs e.g. attention deficit (hyperactivity) disorder, conduct disorder, emotional and behavioural difficulties
Other (Please specify): ……………………………………………………………………………………………………………………………………….
STAYING IN TOUCH
We use text messages and emails to stay in touch with parents and inform them of important information and updates about our services. Please complete the section below so we can keep you updated. Please note that your contact details will not be used for any other purpose or shared with any third party. All information is stored in accordance with the Data Protection Act 1998.
Name ______
Mobile Phone Number: ______
Email:______
Which PACE service(s) do you use?
Fairfield Play Centre
Fairfield Pre-school
Fortune Green Play Centre
Kilburn Grange After School Club
How did you hear about us?
Word of mouth
Child’s School
Flyer/publicity materials
Website
Other ______