PRIMARY YEARS FAMILY DAY
BOOKING FORM
Saturday 22nd October 2016
Maryhill Burgh Halls, 10-24 Gairbraid Avenue, Glasgow, G20 8YE
First Name ………..……………………………………………………………………………
Surname ……………………………………………………......
Relationship to Child:
Parent
Carer
Grandparent
Other
Address 1 ……………………………………………………………......
Address 2 ……………………………………………………………......
Town ……………………………………………………………......
County ……………………………………………………………......
Postcode …..………………………………… ……………………………………………
Telephone Number (preferably mobile telephone) ……………………………………..
Email (we email whenever possible to save on postage and trees)
………………………………………………………………………......
Please confirm your email address ………………………………………………………..
Are you a member of HemiHelp? (You do not need to be a member to attend the event)
Yes No
Other Adults Attending
Adult 2 First Name …………………………………………………………………………..
Adult 2 Surname .………………………………………………………......
Relationship to Child:
Parent
Carer
Grandparent
Other
Adult 3 First Name …………………………………………………………………………..
Adult 3 Surname .………………………………………………………......
Relationship to Child:
Parent
Carer
Grandparent
Other
Adult 4 First Name …………………………………………………………………………..
Adult 4 Surname .………………………………………………………......
Relationship to Child:
Parent
Carer
Grandparent
Other
About You
To help us monitor the effectiveness of our events, please answer the following questions. This information is used when applying to Trusts for essential funding of HemiHelp services.
Is this the first HemiHelp event you have attended?
Yes No
KNOWLEDGE – Please rate each question from 1-5
Before attending the event, how much do you know about the physical and learning barriers that can arise for children with hemiplegia during Primary School?
1 – Nothing
2 – Minimal knowledge
3 – Basic knowledge
4 – Good knowledge
5 – Excellent knowledge
(Please go to Page 3)
Before attending the event, how much do you know about the emotional effects or challenging behaviour that can be common factors with hemiplegia?
1 – Nothing
2 – Minimal knowledge
3 – Basic knowledge
4 – Good knowledge
5 – Excellent knowledge
CONFIDENCE – Please rate your answer from 1-5
Before attending the event, how confident are you in working with the school to support your child
Not confident at all
Somewhat confident
Fairly confident
Very confident
Extremely confident
WHAT DO YOU WANT TO GET OUT OF ATTENDING THIS EVENT?
Please rank from 1-5 how important the following are to you (1-5 where 1 is the LEAST important and 5 is the MOST important)
1 / 2 / 3 / 4 / 5To gain knowledge about how you can help your child’s teacher understand their hemiplegia?
To gain knowledge about the transition from Primary to Secondary School?
To find out more about different perspectives of living with hemiplegia?
To meet other families?
For your child to meet other children with hemiplegia?
Media Consent
PHOTOGRAPHS HemiHelp may take photographs of you and your child participating in activities and use these in internally produced publications (e.g. our magazine, Annual Review, Posters) and/or on our website and social media channels (e.g. Facebook, Twitter, Flickr). As part of our aim to raise awareness of hemiplegia, they may also appear in other targeted print media (e.g. medical/educational publications, local and national newspapers) and approved online channels (e.g. websites/social media).
VIDEO HemiHelp also takes video footage at events to be used in our internally produced videos. These may appear on our website and social media channels (e.g. Facebook, Twitter, our YouTube channel). Please check the relevant box to state your preference on these issues.
YES I am happy for my family’s photographs or videos to be used as stated above.
NO I do NOT want my family’s photographs or videos used by HemiHelp
Other ………………………………………………………………………………………………………………………
Bricks 4 Kidz® WORKSHOP
Please list all children attending this activity
Child 1 - First Name (This should be your child with hemiplegia)
…………………………………………………………………………………
Child 1 – Surname …………………………………………………………………………………
Child 1 – Age …………………………………………………………………………………
Sibling 1 – First Name …………………………………………………………………………………
Sibling 1 – Surname …………………………………………………………………………………
Sibling 1 – Age …………………………………………………………………………………
Sibling 2 – First Name …………………………………………………………………………………
Sibling 2 – Surname …………………………………………………………………………………
Sibling 2 – Age …………………………………………………………………………………
Health & Safety
Please detail below, any relevant medical conditions (apart from hemiplegia) and any medication your child(ren) may currently be taking (e.g. for epilepsy, asthma etc). If there is more than one child on this form, please state the name of the child you are referring to.
…………………………………………………………………………………………………………………
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Please complete and return to
Samantha Lee, HemiHelp, 6 Market Road, London, N7 9PW