SURREY
CHILDREN’S DISABILITY REGISTER
REGISTRATION FORM
When completed this form should be returned to:
The Register Administrator
Surrey Children’s Disability Register
Consort House
5 – 7 Queensway
Redhill
Surrey
RH1 1YB
Phone: 020 8541 8792
Email:
The Surrey Children’s Disability Register is managed by Surrey County Council Children’s Service in partnership with NHS Surrey.
It was established in consultation with parents and voluntary organisations and meets the requirements of the Children Act 1989.
The Children’s Disability Register is held electronically and is subject to the Data Protection Act 1998
If you would like this document in large print, on tape or in another language, please contact the Register Administrator
Please give as much information as possible as this will speed up the registration process.
Note: the term ‘child’ means ‘child or young person’
Information about your Child
Surname: ______First name(s): ______
If your child has been known by any other name, please give details:
Surname: ______First name(s): ______
Male/ female: ______Date of birth: ______
Home address: ______
______
Post code: ______Telephone number: ______
District/borough Council: ______
Religion: ______First language: ______
Ethnic group: please tick the appropriate box to indicate the child’s ethnic background
a / White / b / Mixed / c / Asian Or Asian BritishBritish / White And Black Caribbean / Indian
Irish
Traveller (including Gypsy, Roma or Irish Traveller) / White And Black African / Pakistani
Any Other White Background / White And Asian / Bangladeshi
(Please specify) / Any Other Mixed Background / Any Other Asian Background
(Please specify) / (Please specify)
d / Black Or Black Caribbean / e / Chinese Or Other Ethnic Group
Caribbean / Chinese / I do not wish to answer
African / Other ethnic group
(Please specify)
Any Other Black Background
(Please specify)
Information about Parent/Carer
Information will be sent to the first named parent/carer unless specified otherwise.
*please delete as appropriate
(1) Parent/Carer: *Mr/Mrs/Miss/Ms/other: ______
Surname: ______First Name(s): ______
Date of Birth: ______Relationship to child: ______
Address (if different from address given on Page 2): ______
______
Post code: ______Telephone no: ______Mobile tel no: ______
Email address: ______
Information will be sent electronically where possible
(2) Parent/Carer: *Mr/Mrs/Miss/Ms/other: ______
Surname: ______First Name(s): ______
Date of Birth: ______Relationship to child: ______
Address (if different from address given on Page 2): ______
______
Post code: ______Telephone no: ______Mobile tel no: ______
Email address: ______
Information will be sent electronically where possible
Are you a lone carer? Yes No No
Would you like information about services for carers? Yes NoNo
Would you like information about benefits? Yes NoNo
Benefits
Are you receiving Disability Living Allowance (DLA) for your child, or are they receiving it in their own right? Yes/No
If Yes, please tick which rate he/she is receiving:
Mobility component: Lowest rateHighest rate
Care component:Lowest rateMiddle rateHighest rate
Your child’s needs
Primary need: Please tick one only.
Additional needs: Please tick as many as are applicable.
Primary Additional need needs
Autistic Spectrum DisorderBehavioural, Emotional and Social Difficulties
Developmental Delay
Hearing Impairment
Learning Difficulty/Disability
Medical
Multiple Sensory Impairment (ie hearing & sight loss)
Physical Disability
Profound and Multiple Learning Difficulties (PMLD)
Speech, Language and Communication Difficulties
Severe Learning Difficulty
Visual Impairment
Name given to disability/ies (if known) (eg Downs syndrome) …………………………………………………………….
Do you consider this disability to be mild/moderate/severe? Please delete those that do not apply
Please write below any relevant additional information about your child you would like to provide:
______
______
______
Education
Yes No
Is your child at Early Years/School Action?
or
Is your child at Early Years/School Action Plus
(including a request for assessment for a statement of special
educational needs having been made)?
or
Does your child have a Statement of Special Educational Needs?
Name of current playgroup/nursery/school/college ______
A child does not need to have a statement of special educational needs to be on the
Children’s Disability Register
Self-help skills
Please tick the boxes which best describe your child’s ability to manage the tasks listed as compared to a child of a similar age without a disability:
Able to do / Able to dowith help / Not able
to do / Not
applicable
Independent living skills
eg: using money, independent
travel, accessing leisure / / / /
Social skills
eg: managing in social situations,
letting people know their needs / / / /
Personal care skills
eg: bathing, cleaning teeth / / / /
Independent use of the toilet / / / /
Getting around inside your home or other building / / / /
Getting around outside / / / /
Going up or down stairs / / / /
Getting dressed or undressed / / / /
Getting in or out of bed / / / /
Eating or drinking / / / /
Communication
Is English your child’s first or preferred language?Yes No
If No, please state first language: ………………………………………..…………………………….
Does your child use or understand a signing system or sign language? Yes No
If Yes, which type? Eg Makaton, BSL etc …….………………………………………………….
Is your child an independent communicator? Yes No
Is your child known to Surrey Association for Visual Impairment (SAVI)?Yes No
Is your child known to Surrey Deaf Services?Yes No
Health
Please give details of your child’s GP:
Name: ______
Surgery address: ______
______
Post code: ______Telephone number: ______
Email: ______
Please give details of your child’s Consultant Community Paediatrician/ Hospital Consultant (if applicable)
Name: ______Position: ______
Hospital address: ______
Post code: ______Telephone number: ______
Email: ______
Consent for Registration (To be completed by parent/carer)
I/we agree to my/our child’s name being included in the Surrey Children’s Disability Register.
I/we understand that the information collected will only be shared with those professionals who have a need to know in Surrey County Council and NHS Surrey.
I/weconsent to our information being passed to voluntary organisations who may wish to send us information Yes/No
Signed: ______Name: ______
Date: ______
For statistical purposes, please can you let us know where you found out about the Children’s Disability Register:
School Health centreGPChildren’s Centre
WebsiteSocial WorkerVol orgCAMHS
Other
May 2010
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