Please Choose One Or Both of the Following Benefits

Children with Additional Needs
(CAN) Network Application Form

The CAN Network is part of Wokingham Borough Council and is an information and support servicefor children and young people(up to age 25)and their families,who live in the Wokingham Borough. Children and Young peopledo not need to have a diagnosis to join the CAN Network but cannot obtain a CAN card without evidence of their additional need. The CAN card is recognised by many local leisure attractions and may enable some concessions.

Please choose one or both of the following benefits:

I wish to join the CAN Network to receive regular news emails ofwhat is happening locally, activities, consultations and access to the CAN network Co-ordinator for signposting of advice and information.

I wish to apply for a CAN Card

CAN cards are renewed every 3 years. New and out of date cards will be issued FREE. However, there will be a charge of £5 for the re-issue of a current card within its lifetime due to it being lost or mislaid. If there are any issues around the cost and affording a re-issued card, please discuss with the CAN co-ordinator, (contact details below).

If you would like a CAN card please enclose (or email) a head and shoulders photo of your child/young person (any size), which will be returned to you.Based on the information completed in this form, the CAN Network maintains astatutory register for the Wokingham Borough,which is used to help shape service provision.The information you provide will be treated as confidential and will only be used statistically by other services. No identifying personal information will be passed to any other organisation without prior consent from a parent or carer. The CAN Network is not linked in any way to other statutory registers or databases.Please be aware that completion of this form does not mean that your child/young person or family will automatically receive a service from any of the statutory or voluntary agencies.

The CAN network may send you from time to time, information or requests for consultation from a third party if it is deemed relevant to children, young people and young adults with additional needs.

Thank you for your time in completing this form. Please allow up to 14 days for processing. If you would like any further information, pleasedo not hesitate to get in touch with the CAN Network. Please contact the CAN Network if there is any change to your personal information

Contact the CAN network:email: CAN lephone: 0118 974 6818 or 07789652168

Address: as above

Child/Young Person

First Name: / Surname:
Gender: / Male Female / Date of Birth:

Parent/Carer Details

First Name: / Surname:
Relationship to CH/YP

Contact Details

Address:
Telephone Number: / Home: Mobile:
Email address:

Ethnic Background

White – British / Mixed – Wh/Blk Carribean / Other Asian or British background
White – Irish / Mixed – White and Asian / Black or Black British – Caribbean
White – Traveller of Irish Heritage / Mixed – Other / Black or Black British – African
White – Gypsy/Roma / Asian or British – Indian / Other Black or Black British
White – Other / Asian or British – Pakistani / Chinese
Mixed – Wh/Blk African / Asian or British - Bangladeshi / Other
I do not wish an ethnic background to category to be recorded

PTO

Primary additional need / disability of child/young person (please use separate sheet of paper if needed)

Secondary additional need / disability (if any) that apply

Tell us briefly how the above impacts on daily and family life

What documentation have you sent as evidence of the above additional needs/disability? (Please send copies only as we are unable to return these. We will upload to our secure database and shred the document). E.g. DLA/PIP letter, diagnosis / assessment letter, GP letter, Senco letter etc.

Education / Employment – please tell us where your child or young person is being educated or working.

Does he/she have an Education, Health and Care Plan, or Statement of Special Education Needs? Yes No

Does he/she receive Disability Living Allowance or Personal Independence Payment? Yes No

How did you find out about the CAN network?

Consent for Registration

I agree to the above child or young person’s details being included on the Wokingham Young People’s Disability Register. The information will be held on a pass worded computer on a protected database. Under the Data Protection Act 1998, you have a right to see, update, or withdraw information held at any time.

Signature of Parent/Carer/Young person______

Print name______

Date______

The CAN network will share information with you, but cannot give a personal endorsement – the CAN network asks if you have experienced any services and/or activities, please let others know via the CAN network! If, at any time you do not wish to receive further emails from the CAN network, please let us know and we will remove your email address from our contact list.

Local offer for children with additional needs

Directory of organisations and activities locally and further afield