DWICA: Children & Young People
Sign up form
Childs Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Ethnicity/ Nationality
Current School
*
Child 2
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Ethnicity/ Nationality
Current School
Child 3
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Ethnicity/ Nationality
Current School
Parent/Carer Name
*
First Name
Last Name
Parent/Carer Phone Number
*
Please enter a valid phone number.
Additional Contact Number (optional)
Please enter a valid phone number.
Additional Contact Name
First Name
Last Name
Child Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Carer Email
*
example@example.com
What club do you want to join? (The more the merrier!!)
*
Be Dramatic (Drama Club- Friday 5-6:30pm)
Soca Fitness (Exercise/Dance- Tuesday 5- 6:15pm)
Self Care Saturdays (Wellbeing/Arts&Crafts- Saturday 1-3pm)
Does your child/young person have any allergies? (Attending self-Care Saturday club)
Please answer the following questions about your young person(s).
What do you most hope your child/young person gains from attending our club(s)?
*
Have fun, entertainment
Social interaction
Develop skills and abilities
To support mental health and wellbeing
How has your child/young person found lock down?
*
Very difficult
Difficult at times
Difficult occasionally
They have not found it difficult
How does your child young person access remote learning?
*
Home mobile
Home computer
Home tablet
School equipment loan
DWICA tablet loan
Other
What are your main concern(s) about the impact of lockdown on your child/young person?
*
Education
Social skills
Physical health
Mental health
Other
To what extent is your child/young person isolated at the moment?
*
Very Isolated
1
2
3
4
Not isolated at all
5
1 is Very Isolated, 5 is Not isolated at all
How would you rate your child/young persons awareness of society & their heritage?
*
Very low
1
2
3
4
Very high
5
1 is Very low, 5 is Very high
How would you rate your child/young persons communication skills?
*
Very poor
1
2
3
4
Very good
5
1 is Very poor, 5 is Very good
How would you rate your child/young persons self esteem?
*
Very low
1
2
3
4
Very high
5
1 is Very low, 5 is Very high
How active would you say your child/young person is currently?
*
Very un-active
1
2
3
4
Very active
5
1 is Very un-active, 5 is Very active
Does your child/young person require special resources? i.e. left-handed scissors, tablet hire.
Are there any other ways we can support you and your family at DWICA?
How did you hear about us?
*
Please Select
Website
Facebook
WhatsApp
Twitter
Email
Other
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