Form
Butterflies Club Registration Form
Butterflies Group
Childs first and last Name
Child's Current Age
Child’s date of birth
Name of child's school / education provider
Is your child entitled to benefits based free school meals?
Yes
No
Parent/ Guardians first and last name
Parent/ guardians email address
Parent/ guardians phone number 1
Parent/ guardians phone number 2
Emergency contact name, number & relationship to the child.
If parent/ guardian is not available
Child’s address:
Please enter your child’s Essex shortbreaks number:
If your child does not yet have an Essex shortbreaks number you can apply for these on the Essex shortbreaks website. If you are not eligible please input N/A
Please enter your email address that is linked to your child's shortbreaks account:
If your child does not yet have an Essex shortbreaks number you can apply for these on the Essex shortbreaks website. If you are not eligible please input N/A
Please state any diagnosis of disability
Eg Autism, ADHD, Cerebral Palsy...
Does your child have any medical diagnosis
Eg epilepsy, asthma, dysphalgia..
Does your child carry emergency medication eg midazolam/ epipen
If so please state what it is
Please give a list of your child's regular medications and medication timings over a 24 hour period.
Information of child's GP
GP Name and surgery address
It is the responsibility of parents/ guardians to ensure that any medication brought to clubs is in the original pharmacy packaging with visible pharmacy label stating the child's name, medication name, medication dosage, medication use by date. If the label is not visible or medication appears damaged the medication will not be administered. All medication must be handed directly to the staff member signing the children into the club and then signed over to the parent/ carer collecting the child at the end of the session.
I have read the statement and I understand that it is my responsibility to ensure my child's medication is in the original packaging with the label clearly visible and handed directly to a member of staff.
Please give any information relating to your child’s diagnosis relevant to their time at club sessions
Does your child have any allergies/ food intolerance?
If so please state what they are allergic to and if they are life threatening allergies, mild allergies or intollerance
Does your child have any religious/ ethical dietary requirements you require us to put in place for your child?
Does your child display any challenging behaviours? If so please state what the behaviours are, if there are any known triggers and how you manage the behaviours.
Do you give consent for your child to be included in photographs at Butterflies Club, please note these may be used on social media, our website or on promotional material.
Yes
No
Do you give Butterflies staff consent to administer emergency first aid to your child if required?
Yes
No
Do you give Butterflies staff consent to seek medical attention for your child in an emergency?
Yes
No
Please state if your child needs any assistance in regards to personal care
Eg my child wears pads/ my child needs prompting to use the toilet / none required
We do not allow children/ young people to bring phones/ electronic devices or any personal toys from home into sessions.
Please tick to show you understand that your child must not bring in personal items or any electronic devices on any Butterflies activity and you will support us to ensure they are not brought in.
Do you give consent for your child to access local community activities during their sessions?
Yes
No
Do you give consent for your child to to travel using our Butterflies minibuses?
Yes
No
During trips and local activities children may wish to use the park or soft play equipment. Do you give consent for your child to use this equipment whilst in the care of Butterflies staff?
Yes
No
It is the responsibility of parents/ guardians to ensure that their child is already wearing sun protection on the arrival for activities with Butterflies. Butterflies staff are not responsible for administering sun protection for members.
I have read the statement and I understand that it is my responsibility to ensure my child is wearing sun protection on arrival to Butterflies activities.
It is the responsibility of parents/ guardians to ensure that their child is already wearing weather and activity appropriate clothing on the arrival for activities with Butterflies. Butterflies staff are not responsible for ensuring the children are wearing appropriate clothing.
I have read the statement and I understand that it is my responsibility to ensure my child is wearing weather and activity appropriate clothing on arrival to Butterflies activities.
Please upload an image of your child’s Nimbus Disability Access card.
Browse Files
Drag and drop files here
Choose a file
If your child does not yet have one, you can apply here: https://app.accesscard.online/apply/access-card
Cancel
of
What are your child’s main interests?
What activities are you most interested in for your child at Butterflies Club
Weekend day time multi-Activity Sessions
After school clubs with transport from school
Performing Arts sessions
Cooking Sessions
Swimming Sessions
Community Activities
Day Trips
School Holiday Clubs
Theme Days
1:1 sensory sessions
Weekend evening clubs (clubhouse babysitting services)
Alternative Education provision
Home Education Groups
Age 18+ Daytime provision
Age 18+ Work experience opportunities
What areas are interested in for your child at Butterflies Club
Hockley
Basildon
Brentwood
Canvey
A12 BP Collection
Butterflies Clubs will create a database of the data included in this form which will be password protected, with staff having the ability to access the data prior to your child attending sessions and within the sessions your child is attending to ensure they have all the correct information to provide the level of care required.
I have read the statement and I understand that information I share in this document will be included in my child's file on the Butterflies database, for Butterflies staff to be able to support my child within the sessions.
Submit
Should be Empty: