B&NEs Groups Registration Form
Are you a professional filling out this form on behalf of a parent/carer?
*
Yes
No
Name of professional
*
First Name
Last Name
Email of professional
example@example.com
Phone Number
*
Please enter a valid phone number.
Organisation/Service
*
I can confirm that I have received consent from the parents/carers of the child or young person I am referring to share the below information with WECIL
*
Yes
Child or Young Person Basic Information
Child or Young Person
Is this a new form or an update to a previous form?
*
New Form
Update to a previous form
Name:
*
First Name
Last Name
Child or Young Persons preferred name:
If different to their actual name
Date of Birth:
*
/
Day
/
Month
Year
Date Picker Icon
What gender does your child identify as?
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Male
Female
Prefer not to say
Other
Name of School
Ethnicity
*
Please Select
White - British
White - Irish
White - Gypsy (Including English, Scottish and Roma Gypsy) or Irish Traveller
White - Eastern European
White - Other
Mixed Dual Background - White and Black Caribbean
Mixed Dual Background - White and Black African (non Somali)
Mixed Dual Background - White and Asian
Mixed Dual Background - Other
Asian or Asian British - Indian
Asian or Asian British - Pakistani
Asian or Asian British - Bangladeshi
Asian or Asian British - Chinese
Asian or Asian British - Other
Black or Black British - Caribbean
Black or Black British - African
Black or Black British - Somali
Black or Black British - Other
Other - Arab
Other - Iranian
Other - Kurdish
Other - Iraqi
Other - Turkish
Other
Prefer not to say
Type of Education
*
Mainstream
Special
Residential
Hospital
Other
Parent/Carer Basic Information
Parent or Carer
Name
*
First Name
Last Name
Relationship to Child or Young Person
*
Mobile Phone Number
*
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postcode
Does the family have access to a car?
*
Yes
No
Any parent/carer support needs/disability
*
Yes
No
Details on parent/carer support needs/disability
Emergency Contact Information
Emergency Contact Information
This should be a different contact to the parent/carer contact information added above
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Relationship to Child or Young Person
*
Permissions and Consent
Permissions and Consent
I give consent for my child to undergo emergency treatment if necessary
*
Yes
No
I give permission for photographs, videos and other recorded information of my child to be used in publicity materials, social media, websites for WECIL.
*
Yes
No
I give permission for my child to participate in local trips/off site activities.
*
Yes
No
To ensure the continued funding of WECIL's B&NEs Groups we must regularly update our funders with information about the children and young people we support. Please tick to indicate you give permission for WECIL to share information provided with B&NEs Council.
*
Yes
No
I am happy for WECIL to send me newsletters and information
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Yes
No
I give permission for my child’s school and/or B&NEs Council to share my child’s EHCP with WECIL
*
Yes
No
Signature
I am signing this on behalf of the parent/carer and can confirm I have received consent to do so
*
Yes
Disability Information
Disability Information
Does your child have a social worker?
*
Yes
No
Social Workers Name
Social Workers Phone Number
Please enter a valid phone number.
Please indicate if any of the impairments/disabilities below are relevant to your child:
*
Autism Spectrum Condition
Mental/Emotional Distress
Challenging Behaviour
Physical Impairment
Sensory Impairment
Complex Health Needs
Deaf (BSL User)
Speech Impairment
Visual Impairment
Learning Difficulties (Mild)
Learning Difficulties (Moderate-Severe)
Long Limiting Illness
Prefer not to answer
Other
Please provide further details with regards to your child's needs below.
The more information you provide the better we will be able to identify appropriate support for your child.
Behaviour
*
Communication (Sign, Makaton, Verbal, Non-Verbal etc.)
Individual Support Needs
Does your Child or Young Person require support with personal care?
*
Yes
No
Please provide further details where necessary:
Dietary Requirements
Does your Child or Young Person require support with eating or drinking?
*
Yes
No
Please provide further details where necessary:
Does your Child or Young Person Abscond?
*
Yes
No
Please provide further details where necessary:
Does your Child or Young Person have any phobias?
*
Yes
No
Please provide further details where necessary:
Please provide details of any religious or cultural requirements we need to be aware of:
Please provide further information you feel like we should know about your child or young persons needs including if you have already been in contact with WECIL
Please upload any Care Plans, EHCP's etc. That you feel would be beneficial for supporting your child or young person.
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Medical Information
Medical Information
Does your Child or Young Person have any Allergies?
*
Yes
No
Please provide details of their allergies:
Does your Child or Young Person have Asthma?
*
Yes
No
Does your Child or Young Person have an emergency inhaler?
*
Yes
No
Please provide any further details on their Asthma:
Does your Child or Young Person have Epilepsy?
*
Yes
No
Do they require Epilepsy medication?
*
Yes
No
Please provide any further details on their Epilepsy:
Please upload any relevant Epilepsy Plans and/or Risk assessment's
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Are there any other medical conditions we need to know about?
*
Yes
No
Please provide further details:
Does the Child or Young Person take any medication?
*
Yes
No
Please provide further details:
Please provide further details on anything you feel like we should know about your child or young persons medical needs:
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