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

Email

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

Email

Fullname Address

Relationshiptochild Home telno Mobiletelno

Email

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 ______