NSA Holiday Playschemes

Autism Concern

Admissionand Permission Form

Scheme: Activity Days Youth GroupJunior Go 4 It “Out & About”

Please tick the scheme you are applying for

FAMILY DETAILS

Child’s Surname:……………………………………………………………………………………

Child’s birth name:………………………………………………………………………………….

Any other name the child is called:………………………………………………………………..

Child’s date of birth:…………………………………… Age:…………………………

Parent(s)’s/ carer(s) names:……………………………………………………………………….

Address: ……………………………………………………………………………………………..

……………………………………………………………Postcode……………………..

Contact Numbers:

Telephone(home)…………………………………..

Mum (work)…….……………………………………Mobile: ………………………..

Dad (work)…….…………………………………….Mobile: …………………………

Email……………………………………………………………………………………………………..

Parent(s)’s place of work……………………………………………………………………………….

Alternative Emergency Contact Details

Please give us the contact details of at least two people we can contact in the event of an emergency, if we are unable to contact you.

Alternative emergency contact 1

Name: ……………………………………………………….Relationship: ………………………….

Telephone: ………………………………………………….

Alternative emergency contact 2

Name: ……………………………………………………….Relationship: ………………………….

Telephone: ………………………………………………….

MEDICAL INFORMATION ABOUT YOUR CHILD

Child’s name………………………………………………..…Date of birth………………......

Does your child have any condition requiring medical treatment, including medication?

Yes No If yes please give brief details. If medication is required please include all

details even if this is not to be administered on the day.

…………………………………………………………………………………………………………….…

……………………………………………………......

When did your child last have a tetanus injection?

…………………………………………………………………..

Is your child allergic to any medication?

Yes No If yes please specify………………………………………………………………

Is your child allergic to any food or other substances?

Yes No If yes please specify ………………………………………………………………….

Any special dietary/ feeding requirements

Yes No If yes, please give details: ……………………………………………………………

……………………………………………………………………………………………………………………

Name of G.P: ……………………………………………….Telephone: ………………………………

Address: ……………………………………………………………………………………………………….

…………………………………………………………………………………………………………………..

Parent Permission to Administer Emergency Medical Treatment

I / we consent to my child receiving any emergency medical, surgical or dental treatment, including anaesthetics as deemed necessary by medical authorities, if I cannot be contacted to authorise this.

I / we authorise the Play Leader or their designated representative to sign any document required by the hospital authorities on my behalf.

Signed…………………………………………...

Full name………………………………………………………………… (block capitals please)

Date………………………………………………

DETAILS ABOUT YOUR CHILDthat will help us settle him/her in and manage their needs.

Primary condition(e.g. Autism, Asperger)………………………………………………………….

Additional conditions…………………………………………………………………………………..

Which school do they attend? ......

Do they have a statement of special educational needs?Yes No

How do they communicate?VerbalNon-verbal

Uses:WordsPicturesObjectsPECs

Do you have special words, gestures or signs for things your child understands/uses?

(e.g. for drink, toilet, name of self or others)

…………………………………………………………………………………………………………………

Do they use a schedule at school or home? YesNo

If so what sort? ……..……………………………………………………………………………………….

What causes your child particular distress? How do you deal with it if it occurs?

………………………………………………………………………………………………………………….

What in particular comforts your child?

………………………………………………………………………………………………………………….

What are their current interests?

…………………………………………………………………………………………………….……………

………………………………………………………………………………………………………………….

Are you happy for us to contact your child’s school for information that will help us plan and structure your child’s day? (please circle) Yes No

Please give us any information about anything else that is special about your child’s needs

………………………………………………………………………………………………………………….

Names of Siblings

………………………………………………………….Age………………………

TOILETING/INTIMATE CARE

Child’s name: …………………………………………………………………………………………………

Please tick as appropriate:

My child will request toiletYesNo

My child will say…………………………………………………………………………….to indicate toilet

My child uses toilet independentlyYesNo

My child is independent with verbal/ visual prompts

My child will need some hand over hand help (please specify)

…………………………………………………………………………………………………………….……

………………………………………………………………………………………………………………….

My child is in pull ups YesNo

My child is in padsYesNo

My child has a verbal/ visual routine: (please detail)

………………………………………………………………………………………………………….………

……………………………………………………………………………………………………….…………

My child can manage their intimate care YesNo

Please make staff aware, on the day, if your daughter is on a period or likely to start a period.

Please supply, pads, pull ups, wipes etc.

Sun protection: (please tick relevant box)

I agree to provide sun cream and sun hat and to staff applying sun cream as necessary in line with the Autism Concern policy.

I agree to Autism Concern providing hypo allergenic sun cream and to staff applying sun cream as necessary in line with Autism Concern’s policy.

Parental Permission for Photographs

Child’s name …………………………………………………Date of birth……………….………….

I agree to photographic and video images being taken of my child whilst attending an Activity Day and am happy for photographs to be used in advertising, newsletters, and local newspaper articles and to support the training of Activity Day team members and others interested in developing their knowledge of Autism.

YesNo

I am happy for my child to be identified by name.

YesNo

Registration photograph I enclose a photograph of my child for registration purposes

(Please write your child’s name on the back of the photograph)

YesNo

Data Protection

In order to secure continued funding we are being asked to share information with the Disabled Children’s Team, Northamptonshire County Council and the Department of Education about the children we serve. This data is used to monitor the activity of each service provider and thereby measure the impact of the Aiming High initiative.

The Information they need is:

Full name of child,
gender
date of birth,
nature of disability
Ethnicity.
number of days they attended,

We are formally seeking your permission to share this data with them and would ask that you tick below.

I give permission for data to be shared with the Department of Education

I do not give my permission for data to be shared

Agreement to Terms and Conditions

I have read the Parent Information Booklet and made myself aware of information relevant to my child’s specific needs.

I have made Autism Concern aware of information about my child that will help them settle him/her in and manage his/ her needs effectively.

I agree to the terms and conditions and I have signed permission form.

Signed…………………………………………...

Full name………………………………………………………………… (block capitals please)

Date………………………………………………

EQUAL OPPORTUNITIES INFORMATION:

Child’s name:…………………………………………………………………………………………………………...

Please indicate if English is your child’s first language YesNo

If no please register their preference………………………………………………………………………………….

Religion…………………………………………………………………………………………………………………...

In order to help us with our records can you please tick the appropriate box

White & British / Black Caribbean / White & Black African / Other White
White & Black Caribbean / Chinese / Pakistani / White & Asian
Indian / Irish / Black African / Bangladeshi
Other Black / Other Mixed / Other Asian / Prefer not to say

Once this form is completed, please fill out the one-page profile which is attached.
(Use additional paper if necessary)
This will provide Autism Concern Staff a better understanding of your child’s needs.

Please return your completed forms to:

Children & Young People Services Manager

Autism Concern

Suite 39-42 Burlington House

369 Wellingborough Road

Northampton

NN1 4EU

Or scan it over to

Or fax it to 01604 239403

December 18