FIG Playscheme for Children with Disabilities Registration/Care Plan Form

FIG Playscheme for Children with Disabilities Registration / Care Plan Form
Child's Name*

First NameLast Name
Date of Birth*

DayMonthYear
Date
Address*

Street Address

CityCounty

Post Code
Home Phone Number

Area CodePhone Number
Mobile Phone Number*
Please enter a valid phone number.Format: 00000-000000.
Email Address*
example@example.com
Language Spoken (if applicable)
Ethnic Origin*
Religion (State 'None' if not applicable)
Name of Child's School*
Name of Main Carer (& Contact details if different to those given above)*
Main Carer - Relationship to Child*
Does this person have parental responsibility for this child?*
Does anyone else have parental responsibility for this child?*
If yes to the above, please give name, address & relationship to child:

EMERGENCY CONTACTS

We need the names and addresses of two people who can be contacted in the case of an emergency - this cannot be the main parent/carer detailed on the front page. Children will not be able to be accepted onto the playscheme by supervisors unless 2 emergency contacts other than their parent/carer have been provided. Please take care to write numbers careflly as if we are unable to contact you, these are the numbers that will be contacted should your child take ill or have an accident. If any of the numbers you have supplied change before you child attends Playscheme, please notify us immediately.
Emergency Contact 1 - Name*
Emergency Contact 1 - Relationship to child*
Emergency Contact 1 - Telephone Number(s)*
Emergency Contact 2 - Name*
Emergency Contact 2 - Relationship to child*
Emergency Contact 2 - Telephone Number(s)*
G.P. Name & Contact Number*
Are all of your child's immunisations up to date?*
PLAYSCHEME TRANSPORT

Your child may be entitled to receive transport to and from the Playscheme. Please let us know if this is essential. (Please note that transport for outings is provided for all children as usual).
Is the provision of transport essential for your child to get to and from Playscheme?*
My child will use a wheelchair at playschemeMy child will use a buggy at playschemeMy child needs to travel on the bus in his/her wheelchairMy child requires a houdini harness when on the bus
If transport is essential, please state why:

Disability Information
Please give the diagnostic name for your child's disability/condition:*
Please use this space to provide any further relevant information on your child's needs and disability. Also please note here if there is anything else that we need to know to ensure that we look after your child properly (including behaviour and details of behaviour plans).
Are there any methods, activities or items that we can use in order to help your child settle into playscheme?
Communication
Does your child use sign language? (ie Makaton, BSL)
Please give details of any other ways your child may use to communicate

Toiletting
NappiesPull-upsNot applicable
Please give more information here regarding changing if your child uses nappies or pull-ups
Can your child use the toilet without assistance?*
If your child needs assistance, what help does he/she require?
Does your child have a special word/sign for the toilet?
Eating/Feeding
Does your child eat independently?*
If No, what assistance does your child need with eating?
Is your child Gastro/PEG fed?*
Do you require us to add thickener to your child's fluids?
If yes to the above, please advise how much and ensure you provide this if you would like us to prepare this

Health & Medical Information
Does your child have to take any medication during playscheme hours 10am-3pm? If yes, a medication consent form will be sent to you separately for completion.(Please include the use of asthma inhalers here)*
Does your child suffer from epilepsy or seizures? If yes, a seizure questionnaire will be sent to you separately for completion*
If yes to the above, does your child require any rescue medication? If yes, a medication consent form will be sent to you separately for completion
Does your child have diabetes? If yes, a care plan will be sent to you separately for completion.*
Does your child have any allergies?*
If yes, please give details here:
Does your child require medication in the event of an allergic reaction?
Does your child require an Epipen in the event of an allergic reaction?
If your child does require medication or Epipen in the event of an allergic reaction, we will send our allergy care plan and medication consent forms to you separately for completion
YesNo
Care Plans
Are you aware of a medical care plan that has been completed for your child? If yes, we will send you our care plan form separately for completion. (We are no longer allowed to access school care plans as these are deemed school specific)*
Moving & Handling
Is your child mobile without equipment or support?*
Does your child use a wheelchair?*
Is a sling and hoist ever used to transfer your child?
Are you aware of a moving & handling plan that has been completed for your child? If yes, we will send our Manual Handling Risk Assessment form separately for completion
Do you have any comments or concerns about how your child is moved/handled?
Further Information
Please use this space to provide us with any further relevant information that you would like us to have:
London Borough of Havering (LBH) - Short Breaks Information
We provide Playschemes during most school holidays which are funded by Havering. These Schemes are accessed in one of two way:

1. Your child needs to have been allocated the '100 Hours' of Short Breaks with Havering which can be used with us and/or other providers;

OR

2. Your child needs to have been given a set number of FIG Days in their pacakge of resources awarded by Havering after an assessment.
Prior to us contacting Havering to obtain approval for your child's Playscheme place, it would help us greatly if you are able to please indicate below what your child's Short Breaks allocation is (if known):
Yes
If you know how many hours you have used to date from your 100, please tell us here
Or, if you receive a set number of FIG days allocated within a LBH Resource Package, please give details of the number of days below
Date of Assessment/Letter stating allocation awarded

DayMonthYear
Date

FIG Summer Playscheme for Children with Disabilities
Parental Consent Form

This section must be signed by the Main Carer
Please upload a recent photograph of your child

Cancelof
I have completed this form to the best of my knowledgeI give permission for my child to receive urgent medical treatmentI give permission for my child's school to share information with FIG where allowed, in order to ensure the appropriate care for my childI give permission to FIG to contact my child's school if further information is required regarding his/her behavioural needsI give permission for my child to take part in all activities and outings organised by the Playscheme that I have booked him/her ontoI give permission for FIG's sun cream to be applied if I forget to send in my ownBy accepting a place on the FIG Playscheme, I acknowledge that my child's personal details will be shared with the Local Authority who fund the SchemeI confirm that I have received a copy of the FIG Playgroup & Playscheme Privacy Notice
I give permission for my child's photograph to be used for publicity by FIG & LBH or for display at the Playscheme*
If my child is in a group photo, I give permission for copies of the photo to be given to parents of all the children in it*
Full Name of Parent/Guardian*

First NameLast Name
Signature*

Clear
Date*

DayMonthYear
Date
Should be Empty:

FIG Playscheme for Children with Disabilities Registration / Care Plan Form

Disability Information

Communication

Toiletting

Eating/Feeding

Health & Medical Information

If your child does require medication or Epipen in the event of an allergic reaction, we will send our allergy care plan and medication consent forms to you separately for completion

Care Plans

Moving & Handling

Further Information

London Borough of Havering (LBH) - Short Breaks Information

FIG Summer Playscheme for Children with Disabilities