Thank You for Your Interest in Extratime S Youth Club for Your Child/Young Person

Dear Parent carer,

Thank you for your interest in Extratime’s Youth Club for your child/young person.

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 and schemes where everyone is welcome, children and young people 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 high staffing ratios (often one to one for children and young people who need this) allow our youth workers to support everyone to have fun, try new things and make friends, regardless of their ability. We typically have 12-15 young people at each session and activities include games, arts, cookery, dance, drama and lots more.

All of our staff have a wide range of skills and experience within the fields of youth, play work and disability. All staff have enhanced DBS clearance and are fully trained to meet the needs of the children and young people attending.

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

Please be sure to fill it out as fully as possible so that we can offer the best service we can to your child/young person. If any section does not apply to your child/young person please state not applicable (or NA for short).

To cover this administration there is a one-off, non-refundable registration fee of £30.00 for all new children and young people who wish to attend the Youth Club.

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

Best wishes

Extratime,

01273 420580

Access 2 Youth 2017

Section One: Booking Form

Personal Details
Young Person’s name: / Male: ☐ Female: ☐
Date of birth: / Age:
Address:
Postcode:
Home No: / Mobile No:
Email:
School/College
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 pick up your child should you be unable to do so. This should be someone who we can contact between 4-5.30pm weekdays.
1) Name: / Contact No:
Relationship to child:
Address:
Postcode:
2) Name: / Contact No:
Relationship to child:
Address
Postcode:
Venue: Portslade Village Centre, Windlesham Close, Portslade, BN41 2LL
Snack: A healthy snack will be provided, but please send any special snack choices with your child
Arrival& Pick up: Transport will be provided for students coming from Downs View Link College to venue

Students of other Schools will need to be dropped off by Parent – Carers
Pick up by Parent – Carers for everyone at 7pm (or before if you wish)

Each Wednesday (term time only) 4pm – 7pm £12.00 per session
Due to high demand for places we may not be able to allocate all the sessions requested. We will, however, be as fair as we can when allocating sessions.
Please pay £30.00 registration fee along with this booking form to secure your child’s place. We will invoice you every half term for the Youth Club sessions.
Cheque: Please make cheques payable to ‘Extratime’.
Bank Transfer: If you wish to pay by BACs please indicate on this form, our bank account is 00015403 – sort code 40-52-40. Please reference your payment with the child/young person’s surname & YS (Youth Club).
Debit/Credit Payment: You can also make payment using a debit/credit (credit card incurs a 1.5% charge) card by calling the office.
Does anyone else contribute towards the fees (e.g. Social Care/The FED)? Please give details here:
100% Payment via Parent/Carer: BACs ☐ Cheque ☐ Cash ☐
Childcare Voucher ☐ / Amount paid: £
Date paid:
Association:
Amount or %:
Email Address: / Contact No:
Address:
Cancellation & Notice of Bookings:
Parents/Carers/Social Workers must give at least 2 weeks’ notice if they wish to cancel or make amendments to a session. Refunds will not be given if this notice period is not adhered to except under exceptional circumstances.
About your child/young person
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 Youth Club please do so with the supervisor. You will also need to complete a parental consent form for the administration of medicine in Section Three below.
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 appropriate support 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 your child/young person communicate e.g. Makaton, BSL PECS etc:
Does your child understand simple requests? 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 your child/young person 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 your child/young person sit on the floor to eat a snack? Yes ☐ No ☐
Does your child/young person prefer to eat upright i.e. in a chair? Yes ☐ No ☐
What does your child/young person 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 the child/young person respond if called? Yes ☐ No ☐
Does your child/young person 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 professionals 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: Contact number:
Surgery Name & Address:

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 tick yes below to confirm that you agree to the following statement;
I understand that holding personal information relating to each child or young person is essential for the care and safeguarding of children and young people using the projects. I understand that the information I provide may be shared with Extratime employees and with other children's services with whom Extratime works in partnership on a 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

Registered Charity No 1116203