BOOKING FORM /
Thank you for applying for the
Big Splash Hydro pool sessions

Please fill in and complete the questions below. Once we have received your form, we will be in touch to confirm your place.

Name of child or young person with a disability:
Age : / Disability:
Address:
Postcode: / Borough:
School:
Contact Number:
E-Mail Address:
Name of parent/carer attending:

Hydrotherapy Pool Session:

Please highlight your preferred sessions, the date, time and who will be attending. You may choose a maximum of 6 sessions per term, (term time only)

Session
Preference / Date / Time / Name and age of children and number of adults attending in the water
Example / 11/8 / 9 - 10am / 5 - Mum Jane, Dad Joe, Jessica 5, Jenny 15 and Jack 3
Choice 1
Choice 2
Choice 3
Choice 4
Choice 5
Choice 6

Mobility:

Walks unaided / Walks aided with one helper
Use of sticks/crutches / Walker/ frame
Wheelchair (electric) / Wheelchair independent user
Wheelchair dependant user / Hoisted, clips or loops sling? (C/L)
Chair entry (standing transfers only) / Use of disability bars
Use of changing/showering bed / Use of Shower chair

Medical Information:

Please note that all medical and booking form information will be confidential and only seen by the Hydrotherapy Pool management team.

It is important for parents/carers to bring along any emergency medication that is required. Hydrotherapy staff are not able to administer medication.

Please tick any medical conditions that we will need to know about in order to meet the young person or child’s needs:

Breathing difficulties / Asthma / Chest infections / Requires oxygen / Other
Heart problems / Existing condition / Surgically repaired / Stable
Epilepsy / Well controlled / Absence seizure / Tonic/ tonic clonic/ unclassified seizures / Care plan attached
Needs medication after minutes
Blood pressure / High / Low
Additional tubing / Gastrostomy button / Gastrostomy peg / NG Tube / Tracheostomy
Hearing/ visual difficulties / Grommets / Hearing aids/device / Glasses / Registered blind
Muscle tone / High / Low / Spasms / Dystonia
Skin conditions / Eczema / Skin infection / Chlorine allergy / Verrucae
Other / Diabetes / Incontinence / Weight in excess of 160kg / Use of thickeners
Swallowing difficulties / Other
Swimming ability:
Beginner / Intermediate / Advanced / Independent

If any family members or person attending the Hydro Pool sessions has any medical problems or health condition, please specify

Family member / Medical problem / Health condition

Consent Form:

I / (Parent/Carer) of / (Child/young person)
Consent for my child to participate in hydrotherapy/play sessions. / Yes / No
Consent to first aid being administered by a trained first aider whilst attending the Big Splash / Yes / No
Consent for pictures of my child taken in the hydrotherapy pool to be used
On display boards. / Yes / No
On advertising material. / Yes / No
On the Jack Tizard School Website and
The Big Splash Trust Website. / Yes / No
Signed: / Date

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