LEEDS MENCAP PLAYSCHEME Ages 4-8 years

Information sheet 2015/16

We are pleased to advise that we will be running a5day playscheme at our East End Park building from Monday 13th April to Friday 17th April 2015.The playscheme is for children and young people who were aged between 4 and 8 years on 1st September 2014.

There are only a limited number of places which will only be confirmed on receipt of full payment and a completed application form.The charge for attending the playscheme is£15 per day. Cheques should be made payable to: Leeds Mencap.

In order to ensure we have sufficient planning time, please be advised that the last date for applications will be Sunday 29th March 2015. We will not be able to accept applications after that date, and will be in contact in early April to confirm places.

The playscheme will start at 10.00 am and finish at 3.00pm. Young peoplewill need to bring a packed lunch with them every day. We are often over-subscribed and cannot offer children/young people all the days which have been requested. If this is the case, we will reduce the number of days offered to each person so that everyone who wants to attend has the opportunity to do so. Confirmation of places will be sent out in writing. No young person will be accepted on the day without prior booking.

If your child cannot attend due to illness please contact Leeds Mencap’s day time telephone number which is 0113 235 1331. Unfortunately we are not able to refund payment for days which children do not attend because of illness.

Please return all forms and payment to:

Leeds Mencap

Londesboro Terrace

East End Park

Leeds

LS9 9NE

Please retain this sheet for your information.

LondesboroTerrace

East End Park

Leeds

LS9 9NE

Phone: 0113 2351331

Fax: 0113 2496006

email:

Leeds Mencap. Registered Charity No. 1091809 and Company Limited by Guaranteed No. 4332965.

Registered Offices: Leeds Mencap, Londesboro Terrace, East End Park, Leeds, LS9 9NE.

LEEDS MENCAP PLAYSCHEME – AGES 4-8

13th-17th April 2015

It is very important that we can contact you if needed so please make sure mobiles are switched on and contacts available.

Childs Details:

Name

D.O.B

Address

Please tick which days you would like your child to attend

Monday
13th April / Tuesday
14th April / Wednesday 15th April / Thursday 16th April / Friday
17th April / Amount enclosed
£

Emergency contacts (Please give two, including parent / carer)

1.Name:

Relationship:

Contact Number:

2.Name:

Relationship:

Contact Number:

Parent/ Carer details:

Name

Address

(if different from child)

Email Address:

Please tick if we can use your email address for sending out information about:-

Leeds Mencap Groups only Other groups for people with learning disabilities

Home Telephone Number:

Mobile Number:

Medical Information

Doctors Name:

Address:

Telephone Number:

Does your child have a medical condition that requires medication?

YESNO

If yes, please give details of condition and any medication required below.

Please label all medication clearly with child’s name, dose and times given

A separate medication form will be sent out to you.

If nursing cover is required please contact us.

Does your child have a diagnosis?

YESNO

If yes, please provide details

Does your child use a wheelchair?

YESNO

If yes, please provide details

Does your child have any allergies?

YESNO

If yes, please provide details

Toileting:

Does your child require assistance or reminding to use the toilet?

YESNO

If yes, please provide details of what assistance is required or how they prefer to be changed.

If your child is incontinent, please supply nappies/pads, wipes and cream.

Communication:

What form of communication does your child use? E.G. speech, gestures, makaton, pecs, etc.

Language spoken at home:

Behaviour

If your child exhibits any challenging behaviour, please explain how this is managed.

If your child becomes upset how do they like to be comforted?

Does your child require 1:1 care?

YESNO

If yes, please provide details

Diet:

Does your child have any special dietary requirements?

YESNO

If yes, please provide details

Does your child need help with feeding?

YESNO

If yes, please provide details

Likes & Dislikes:

We may be taking the children out on trips to farms, parks and museums (such as Eureka) and other places of interest. Is there anything we should be aware of when taking your child out?

What kind of activities/toys does your child like?

What kind of activities etc. does your child not like? Is there anything that might upset them?

We wish to ensure that your child’s needs are met at Play scheme and a great deal of time is spent ensuring we have the right staffing levels, suitable activities and trips to ensure that the children’s needs are met and that they have lots of fun with us at Play scheme.

Please provide any further information - which will help us to ensure that your child’s needs are met during their time at Play scheme. (Please continue on separate sheet if required)

Consent

I hereby certify that the information given on this form is correct, and -

I give my permission for play scheme staff to:

Administer first aid if needed?

YESNO

To seek medical advice or treatment?

YESNO

To take trips outside of the playscheme building?

YESNO

To go swimming?

YESNO

Please indicate the level of swimming ticking one or two items below.

Non-swimmer limited swimmer must use armbands good swimmer

Signed

Print Name

Date

Membership

For every family who uses a Leeds Mencap service, one family member must become an Associate Member or Full Member. You can become an Associate Member at a cost of £1 or a Full Member for £12 per annum.

Is a member of your family already a member of Leeds Mencap?

YESNO

We need to provide the information on these next two pages to funders to ensure that the play schemes keep running.

Equal Opportunities

Please fill out the next section in order to record the ethnic origin of play scheme attendees. Any information you provide will be kept confidential.

Please tick

White British
White Irish
Traveller of Irish Heritage
Any other White background
Gypsy/Roma
White and Black Caribbean
White and Black African
White and Asian
Any other Mixed background
Indian
Pakistani
Bangladeshi
Any other Asian background
Caribbean
African
Any other Black background
Chinese
Any other ethnic group

Child’s Quick Profile

These categories are used by the funders to monitor our service provision.

Please tick all the categories that your child has difficulty with.

Please tick

Mobility - getting about the house and beyond
Hand Function - holding and touching
Personal Care - washing, going to the toilet, dressing, etc
Incontinence
Communication - speaking and/or understanding others
Learning - special education needs, etc
Hearing impairment
Visual impairment
Behaviour - a condition resulting in socially unacceptable behaviour
Consciousness - fits and seizures
Diagnosed with autism or Asperger Syndrome - by a qualified medical practitioner only
Other DDA - the child's disability under the Disability Discrimination Act 2005 does not fall into any of the above categories

Please circle if you do not give permission for Leeds Mencap to share this information with our funders and local authority departments. NO

Behaviour Policy

  • All members and their families will be treated equally, fairly, kindly and consistently.
  • Every child placed in our care will be respected as a person in their own right.
  • Good behaviour will always be rewarded and praised.
  • It is acknowledged that members are learning new things and will often make mistakes in their actions and social behaviour. It is our aim to help them progress in their behaviour, to their own pace and abilities.
  • Parents will be informed of any particular achievements made by their child.
  • Members will not be labelled, shouted at, told they are bad or stupid.
  • No system of punishment will be used on the play scheme.
  • Members who are causing problems by difficult or unacceptable behaviour* will be removed from the initial situation and a member of staff will talk quietly to them about their behaviour and provide alternative activities.
  • No member will be restrained in any way by a volunteer and will only be gently restrained by a member of staff, should an exceptional and dangerous situation occur.
  • Staff have the right to ask parents/carers to collect/remove any child who exhibits behaviour that is likely to cause harm or distress to other children, staff or themselves.
  • Parents/carers will be fully consulted should a problem occur.

*Definition of unacceptable behaviour for staff and members-

-Swearing

-Hitting

-Rowdiness

-Any behaviour which could bring their or other members, or staff/volunteers safety into jeopardy.

-Any behaviour which discriminates against others abilities, race or sex; which includes disregarding the basic needs or respect for members/staff/volunteers and the building.

-Inappropriate touching.

I have read and understood this behaviour policy

Signed Date

Dear Service User/Guardian,

In order for Leeds Mencap to tell people about our services it would be helpful if we could use photographs/recordings of you/your dependent(s) occasionally. These may be used in any of the following ways:

  • Displays within and outside Leeds Mencap
  • In the Leeds Mencap newsletter
  • In publicity, fundraising and service information literature
  • In publicity and fundraising features in the press
  • In promotional films
  • On the Leeds Mencap website and social media e.g. Facebook and Twitter

Please help to tell us your preference by filling in the form below.

Name of parent/guardian if applicable (CAPITALS)

Relationship of the above contact to service user

Name of service user (CAPITALS)

Service(s) used

Signature Date

Please tick either Agree or Disagree the box below:

If you have agreed to the above, please tick agree or disagree in the box below:

If you wish to withdraw your consent you can do so at any time by contacting or 0113 2351331 we will stop using all photos and recordings and remove all items within 20 working days.