Thank You for Your Interest in Extratime After School Clubs for Your Child

2017

Dear Parent carer,

Thank you for your interest in Extratime after school clubs for your child.

Extratime has been providing play and leisure activities for children and young people with and without additional needs and disabilities since 2003.

Inclusive play is at the heart of everything we do. By providing clubs where everyone is welcome, children of all abilities are able to mix socially and develop through play and leisure activities. This approach also promotes the values of an inclusive society where everyone is treated equally and with respect.

At Extratime after school clubs, high staffing ratios (one to one for children who need this) allow our teams of playworkers to support everyone to have fun, try new things and make friends, regardless of their ability. All of our staff have a wide range of skills and experience within the fields ofplay work and disability. All staff have enhanced DBS clearance and are fully trained to meet the needs of the children attending.

To help us understand and meet your child’s needs, we ask all parent carers to complete thecomprehensive booking pack enclosed. This pack contains sections on booking, personal needs,medication and parental consent. The pack also includes anethnic monitoring form.

Please do fill it out as fully as possible so that we can offer the best service possible to your child. If any section does not apply to your child please state not applicable (N/A for short).

To cover this administration, we usually charge a one-off, non-refundable registration fee of £30.00 for all new children and young people who wish to attend the Extratime after school club. As part of the launch of the scheme, we are waiving this fee as a welcome gift during February & March.

Thank you for the time you spend on the forms – we know it is time consuming but they are essential. If you have any queries at all, please do not hesitate to contact us at .

Best wishes,

Sam Price

Chief Executive

After School Clubs 2017

Section One: Booking Form

Personal Details
Child’s name: / Male Female
Date of birth: / Age:
Address:
Postcode
Home No / Mobile No
Email
School
Form/teacher
Name of Parent carer at home address / Relationship
Is this who will normally collect your child at the end of the session? / Yes No
If no, please give details of the person and their relationship to the child:
Name / Relationship
Address / Contact No
I consent for my child to go home unaccompanied Yes No
Please name 2 other people who can be relied upon to pickup your child should you be unable to do so. This should be someone who we can contact between 4-5.30pm weekdays.
Name / Contact No
Relationship to child
Address & Postcode
Name / Contact No
Relationship to child
Address & Postcode
Hawkins Crescent After School Club
Herons Dale Primary School, Hawkins Crescent, Shoreham-by-Sea, BN43 6TN
2.45pm to 6pm Mon-Fri term time £12 per session (except inset days,normally 4 per year)
Dependent on availability and current waiting lists, which days would you like your child to attend an after school club:
Mon Tues Weds Thurs Fri
Payment of fees
Fees must be paid in full within two weeks of the end of term. The exact date will be provided on each invoice. Failure to pay on time could jeopardise your child’s return to club in the subsequent term.
Payments can be paid by;

1. BACs transfer direct to Extratime bank account; 00015403, sort code 40-52-40.Please reference your payment with your child’s surname & the venue name.
2. Cheque payable to Extratime at Manor Offices Emmaus, Drove Road, Portslade, BN41 2PA.
3. Debit or credit card. Please contact Extratime on 01273 420580

Please note that cash payments cannot be taken at the club venue or be sent by post.
If your child is absent for any reason e.g. ill health, holiday etc. fees are still payable as the place remains allocated solely for your child.
Fees are not charged if there are inset days or bank holidays on a day when your child is normally booked into club. This also applies when the school is closed due to strike action.
Please note that parent’s carers are required to give four weeks’ notice if they no longer wish their child to attend the club.
Does anyone else contribute towards the fees (e.g. Social Care/The FED)? Please give details here.
Contact Name
Service Provider address / Contact No
Email address
About your child
Does your child have any known medical conditions or allergies?
Yes No
If yes, please give details:
If you need to discuss the administration of medication whilst your child is in the care of the after school club, please do so with the supervisor. You will also need to complete a parental consent form for the administration of medicine in Section Threebelow.
Does your child have any likes or dislikes? Any fears which we should know of in order to provide appropriate care to meet his/her needs?
Yes No
If yes, please give details:
Please tell us anything else you feel is relevant to the general care of your child during the session/s. Where more detailed information is required please include this in Section Two.

Section Two: Personal Needs

Please complete this section as fully as possible using extra sheets if needed. The information you give will help us provide appropriatesupport to meet your child’s needs. We realise that you may have filled in numerous forms before of this nature but it is essential to get as much information as we can. In some cases we will follow this up with a telephone call.

Does your child have an additional need or disability? YES NO
If no, please go to Section Three
General Information:
Please describe the nature of your child’s needs, including a defined name if applicable e.g. Down’s Syndrome, autism, deafness etc.
Does your child use any special aids e.g. wheel chair, walking frame, hearing aid etc:
Communication
Is your child able to communicate verbally? Yes No
If NO, how does he/she communicate e.g. Makaton, BSL PECS etc:
Does your child understand simple commands? Yes No
Are there any key words or symbols that you or your young person uses to indicate things?
Does your child take any medication? Yes No
If yes, please give details:
Personal care and hygiene
Does your child need to wear training pads/nappies during the day? Yes No
Is he/she being toilet trained? Yes No
Food and Drink
Does your child need help at snack time? Yes No
If YES please complete the following as appropriate :
Can he/she sit on the floor to eat a snack? Yes No
Does he/she prefer to eat upright i.e. in a chair? Yes No
What does he/she drink from, e.g. a cup with lid or straw:
Is there any food or drink that he/she MUST NOT have, if so, please give details:
General Behaviour
Is your child likely to wander off from the group? Yes No
Will he/she respond if called? Yes No
Does he/she get easily upset or have sudden outbursts? Yes No
If YES, what may cause them to do so and what is the best way to deal with them?
Extratime is committed to ensuring your child /young person is safe and happy whilst with us. On occasions, it may be helpful for us to talk to your child’s teacher or other named professional, or to read your child’s home/school news book for that day, so that we can ensure we are fully able to meet all their needs during their time with us.
Do you give your consent for the supervisor to talk with his/her teacher? Yes No
And consent for the supervisor to talk with their named professional/s? Yes No
Named professional e.g. social worker, respite carer;
Name / Contact no
Name / Contact no

Section Three: Medication

If your child needs to take medication while in Extratime’s care, you will need to complete this Medication section. This applies to both emergency medication and regular medication. Extratime’s Administration of medication policy is available on request and on our website.

Does your child need emergency medication?
Yes No
To be given in the following circumstances / After minutes
Further instructions should a
second dose be necessary / After minutes if (describe circumstances)
Does your child need regular medication?
Yes No
If yes, please give details
Name of medication;
Dose:
Frequency:
Administration methods (e.g. in food / drink etc.):
I request that the treatment be given in accordance with the above information by a responsible member of Extratime’s staff who has received any necessary training. I understand that it may be necessary for this treatment to be carried out during club outings as well as on the club’s premises.
I undertake to supply the club with drugs and medicines in properly labelled containers.
Yes No
Emergency medical treatment
In the unlikely event that your child is involved in an emergency and we are unable to contact you It may also be necessary for us to make decisions about your child’s medical needs. We therefore ask that you consent to Extratime senior management making such a decision if these circumstances occur.
I consent to any emergency medical treatment necessary during the running of the club activities. I authorise staff to sign any written form of consent required by the hospital authorities if the delay in getting my signature is considered by the doctor to endanger my child’s health and safety.
Yes No
In the event of an emergency we may need to contact your child’s GP.
Name of GP: Surgery
Contact number

Consent for administration of non-emergency medicine

If you would like Extratime staff to administer non-emergency medication to your child (e.g. antibiotics or paracetamol), a separate ‘Administration of non-emergency medication’ form must be completed on each occasion. In all cases, Extratime staff will need to discuss this with you in more detail.
In the interests of everyone’s health and well-being, please do not send your children to the after school club if they are unwell.

Section Four: Consent

Sunscreen / face paint

I consent do not consent for sunscreen/face paint to be applied to my child/young person as necessary.

Please also provide a sun hat for your child to wear when appropriate
Photography and video
Sometimes we take photos/videos of the children/young people taking part in our activities. These images may be used for display purposes at the venues, in publicity material, funding applications, on our website and uploads to social media (i.e. Facebook), etc. We will only include your child with permission and at no time mention their name on the materials produced.
I consent do not consent to my child having their image taken whilst at Extratime and used as detailed above
I consent do not consent for partnership agencies to use these images as agreed by Extratime (you would be contacted to discuss this further)
Miscellaneous
I agree for my child to take part in local trips on the understanding that they will return by the end of the session YES NO

Section Five: Data Protection Declaration

Extratime is registered under the 1998 Data Protection Act in respect of personal data that it holds.Please sign below to confirm that you agree to the following statement;
I understand that holding personal information relating to each child or young person isessentialfor the care and safeguarding of children and young peopleusing the projects.I understand that the information I providemay be shared with Extratime employees and with other children's services with whom Extratime works in partnership ona need to know basis.
Yes No
For more information please refer to Extratime’s Data Protection Policy and Information Sharing Policy which are available in all the settings and on our website - If you have any queries or concerns please call us (01273 420580) and we will be very happy to talk it through.

Section Six: Signature

Please sign here to confirm that the above information is accurate to the best of your knowledge.
Signed (parent/carer)
Print Name
Date

Section Seven: Ethnic Monitoring Form

The 1989 Children Act asks that we consider your child / young person’s ethnic origin. We would be grateful if you would complete the following and return it to us anonymously. The information will be used to monitor the numbers of children / young people from all sections of the community using our services. All information will remain strictly confidential.

I would describe my child / young person’s ethnic group as (please tick one)
Black/Black British / Asian/Asian British / White
African / Indian / British
Caribbean / Pakistani / Irish
Any other Black background* / Bangladeshi / Traveller of Irish Heritage
Any other Asian background* / Gypsy/Roma
Any other White background*
Mixed
White & Black Caribbean / Chinese Origin
White & Black African / Other origin*
White & Black Asian
Any other mixed background*
*Please specify
What is the main language you use at home?

The information from this form will be separated from the booking pack and used anonymously by Extratime for equality monitoring and statistical purposes

Thank you

Extratime, Manor Offices Emmaus, Drove Road, Portslade, BN41 2PA

T: 01273 420580 E:

Extratime is a Registered Charity No 1116203

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Registered Charity No 1116203