Butterflies Club Registrations

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?

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.

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.

Do you give Butterflies staff consent to administer emergency first aid to your child if required?

Do you give Butterflies staff consent to seek medical attention for your child in an emergency?

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.

Do you give consent for your child to access local community activities during their sessions?

Do you give consent for your child to to travel using our Butterflies minibuses?

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?

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.

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.

Please upload an image of your child’s Nimbus Disability Access card.

If your child does not yet have one, you can apply here: https://app.accesscard.online/apply/access-card

What are your child’s main interests?

What activities are you most interested in for your child at Butterflies Club

What areas are interested in for your child at Butterflies Club

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.

Form

Butterflies Club Registration Form