Neurodiversity Social Club 10-16 Membership Form

Neurodiversity Social Club 10-17

Waltham Forest
Registration Form

Thank you for signing up to our monthly, parent-led social club for neurodiverse young people resident in Waltham Forest aged 10-17. Most, but not all, of the young people in the group have a diagnosis of autism, ADHD, dyspraxia, dyslexia etc. Most, but not all, are enrolled in mainstream school and have found it difficult. Some, but not all, have an EHCP. Games currently popular in the group are Dungeons & Dragons, Chess, Connect4 and OKPlay or similar. We operate a 1:1 parent/carer to young person attendance ratio.
Young Person's Name*

First NameLast Name
Date of Birth*

DayMonthYear
Date
Young Person's postcode*
Young Person's Ethnic Group*

Asian or Asian BritishBlack, Black British, Caribbean or AfricanMixed or multiple ethnicityWhiteOther ethinic groupPrefer not to say
Name of Young Person's Current School/Education Setting*
Has the Young Person Ever Attended a Mainstream School at KS2 or above? (This is not a barrier to attending but it may be an indication that your Young Person will need additional support to access the group/environment)*

YesNo
Preferred Table Top Games*
Most families bring their own preferred board/tabletop games. We can try to set up some in advance if it helps with transition into space.
Details of any allergies/medical needs*
Diagnoses/Sensory Challenges/Anxieties*
No diagnosis is required to attend. Most, but not all, young people have a diagnosis of autism, adhd or dyspraxia.
Parent/Carer's Name*

First NameLast Name
Parent/Carer's E-mail*
Parent/Carer's Mobile Phone Number*
Is the Parent/Carer over 18?*

Yes
Please confirm that you are happy to be contacted regarding attendance and administration of the group via Whatsapp, phone and/or email.*

Yes
Name of any siblings who will attend (if applicable)
Emergency Contact:
Name, Phone number, Relationship to young person
How did you hear about us?
Any siblings who wish to attend?
Question from our Funders For Your Young Person: How strongly do you feel a sense of connection or belonging to your local area and/or community* ?

Very StronglyFairly StronglyNot Very StronglyNot At All StronglyDon't Know
Question from our Funders For You (parent/carer): How strongly do you feel a sense of connection or belonging to your local area and/or community* ?

Very StronglyFairly StronglyNot Very StronglyNot At All StronglyDon't Know
Thank you for registering for the Social Club. You will need to pre-book for each session as the limitations of space mean that we can't have more than 20 young people attending. Links to the booking forms will be sent out monthly on Whatsapp to all registered members. We will need one booking per neurodiverse child (no booking required for siblings and parents/carers).

Free car parking is available at Mission Grove Car Park (E17 7LD) after 5pm which is less than 100m from The Mill.

If you have any questions please message on Whatsapp on 07949 112 470 or leave any questions about the group in person with Natasha at The Mill, 7-11 Coppermill Lane, London E17 7HA (tel: 020 8521 3211).
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Neurodiversity Social Club 10-17

Registration Form