SEND Form
(Special Educational Needs and Disabilities)
Child's Full Name
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First Name
Last Name
Please attach a photo of your child here
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Address
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Address Line 1
Address Line 2
City
County
Postcode
Mother/Father/Carer's name (1)
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First Name
Last Name
Mother/Father/Carer's name (2)
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First Name
Last Name
Residing at same address as the child?
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Please Select
Yes
No
Other address (where applicable):
Describe if there are any family members living in the home with additional needs:
This may include disabled siblings or family members who need additional care from the primary carer.
Preferred method of contact
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Please Select
Telephone call
Mobile/text
Email
Phone number
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Email
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Mobile
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Emergency Contact Details: Name & relationship
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Emergency Contact's Mobile phone number
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Child's Ethnicity
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Languages spoken at home
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Child's Religion
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Name(s) of sibling(s) attending/applying
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Doctor's Name & address
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Doctor's phone number
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Child's Sex
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Please Select
Male
Female
Child's Primary Disability
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Please Select
ASD
Learning Disability
Communication and Language difficulties
Other (please note below)
School / unit child attends
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Please Select
Marian Vian
Clare House
Hawes Down
Other disability not listed above
Day pupil or residential?
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Please Select
Day Pupil
Residential
Does the child have a Care Plan , Behaviour Management Plan or individual Education Plan at school or home that you can share? (please provide details below)
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Please Select
Yes
No
Undergoing the process
Details of Plan:
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Child's Diagnosis and Additional Needs:
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Please provide a brief description of your child’s disability. In the next section you will record your child’s individual needs.
Personal Care:
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If your child needs to be hoisted for personal care, please ensure they come into the scheme already sitting on their personal sling. Please ensure that you send enough continence products with your child for the day including an extra if they go swimming. You must send your child with any special cup/spoon or eating equipment as necessary.
Describe the level of support that is provided in the school unit:
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Please indicate what level of assistance your child needs with the following tasks:
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None
Low
Medium
High
Eating
Mobility
Toileting
Washing & Dressing
Please describe what level of support is required: Toileting
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e.g., full support, support with wiping, wears pads
Please describe what level of support is required: Washing and Dressing
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e.g., task reminders, help with buttons/zips, complete support
Please describe what level of support is required: Eating
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e.g., food allergies or food products to be avoided (for religious /cultural reasons), help with food cut up/ mashed, opening packets, support to remain at the table, etc
Please describe what level of support is required: Mobility
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e.g. no difficulties, wheelchair, walker, additional supervision due to running
Describe your child's main method of communication:
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How does your child make his/her needs known?
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e.g. Easily with no additional help or some difficulty, with support
Describe any non-verbal communication that may help us understand your child better:
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Describe any activities that should be avoided at the scheme and reason why:
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Describe how your child relates to other children:
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Please describe why and when your child may need close supervision:
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Please provide details the type of activity that requires closer supervisione.g., group activities, community outings, eating, road safety, etc.
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Does your child display any challenging behaviour?
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Please Select
Yes - please describe below
No
Unlikely but possible - please describe below
Please describe where yes or possible:
Are there any situations or events that make your child anxious?
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Please Select
Yes - please describe below
No
Please describe where yes:
In the event of my child being involved in an accident whilst attending an activity, I understand that every effort will be made to contact the parent/ carer. If they cannot be reached please indicate give authorisation below for trained staff to undertake basic first aid and for medical staff to undertake any treatment that the child requires.
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Please Select
Yes - I give consent for the child to receive First Aid as above
No - I do not give consent for my child to receive First Aid as above
Medication: Does the child require medication?
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Please Select
Yes
No
To be completed by the parent/carer of any child to whom drugs may be administered under the supervision of staff. Wherever possible, children who are prescribed medication should receive their doses at home. If it is necessary for medication to be taken during sessions at the play scheme then it will be given by a competent and First Aid trained professional.
Please give details of all medications prescribed, including those required in an emergency: medicine to be given, how often (e.g. lunchtime after food), dosage, how it is administered, storage requirements, to be given regularly or in an emergency:
Can the child administer the medication him/herself under supervision?
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Please Select
Yes
No
Authorisation to administer medicine
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Please Select
I request that the medication be given in accordance with the above information by a responsible member of staff who has received any necessary training. I understand that it may be necessary for the medication to be given during visits off site as well as on the premises. I undertake to supply the medicines in their original packaging as prescribed by a doctor ensuring that containers are properly labelled and that the medication is in date.
Please indicate permissions for children to be taken off site on local trips whilst attending the play scheme:
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Please Select
Yes - I give authorisation for my child to be taken offsite on local trips whilst attending the play scheme.
No - I DO NOT give authorisation for my child to be taken offsite on local trips whilst attending the play scheme.
e.g. local park, shops
Permission for children to access the internet whist at the play scheme:
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Please Select
Yes
No
(parental controls are already in place at school; i.e., no access to YouTube etc.)
Photographic consent: photographs may be taken of the child and I acknowledge that copyright of such photography belongs to the photographer and that the providers may use the photographs in any publication or promotion in relation to this provision:
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Please Select
Yes - I give authorisation for photographs may be taken of the child and I acknowledge that copyright of such photography belongs to the photographer and that the providers may use the photographs in any publication or promotion in relation to this provision.
No - I DO NOT give authorisation for photographs may be taken of the child and I acknowledge that copyright of such photography belongs to the photographer and that the providers may use the photographs in any publication or promotion in relation to this provision.
Consent for Confidentiality and Child Protection
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Please Select
I give my consent for Chucklebox to inform the Disabled Children’s Team in the event of an issue arising with regard to Child Protection and acknowledge that they will take into account the rights and wishes of the child in line with Child Protection procedures.
Data Exchange: All information will be forwarded to the Disabled Children’s Social Work and Short Break Team who will make the final decision whether your child is eligible for a short break at the scheme.
*
Please Select
I give consent for information to be shared with other relevant professionals involved in my child’s care whilst at the scheme.
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