• Are you a professional filling out this form on behalf of a parent/carer?*
  • Format: 00000000000.
  • Have you completed a referral to the Holiday Short Breaks Service (HSB)*

  • Please note Children and Young People should only be referred to either Out and About or Holiday Short Breaks. Referrals should NOT be made to both services.

    • Child or Young Person Basic Information 
    • Child or Young Person

      Child or Young Person

    • Is this a new form or an update to a previous form?*
    • What service do you attend?*
    • Date of Birth: *
       / /
    • What gender does your child identify as?*
    • Type of Education*
    • Parent/Carer Basic Information 
    • Parent or Carer

      Parent or Carer

    • Format: 00000000000.
    • Format: 00000000000.
    • Does the family have access to a car?*
    • Any parent/carer support needs/disability*
    • Emergency Contact Information 
    • Emergency Contact Information

      Emergency Contact Information

      This should be a different contact to the parent/carer contact information added above
    • Format: 00000000000.
    • Permissions and Consent 
    • Permissions and Consent

      Permissions and Consent

    • I give consent for my child to undergo emergency treatment if necessary*
    • I give permission for photographs, videos and other recorded information of my child to be used in publicity materials, social media, websites for the overall consortium, each consortium provider and Bristol City Council.*
    • I give permission for my child to participate in local trips/off site activities.*
    • To ensure the continued funding of Out and About we must regularly update our funders with information about the children and young people we support. Please tick to indicate you give permission for the Out and About consortium to share information provided within the consortium and with Bristol City Council.*
    • I am happy for the consortium to send me newsletters and information*
    • I give permission for my child’s school and/or Bristol City Council to share my child’s EHCP with WECIL and the Out and About Consoritum Providers*
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    • Disability Information  
    • Disability Information

      Disability Information

    • Does your child have a social worker?*
    • Format: 00000000000.
    • Please indicate if any of the impairments/disabilities below are relevant to your child:*

    • 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.
    • Does your Child or Young Person require support with personal care?*
    • Does your Child or Young Person require support with eating or drinking?*
    • Does your Child or Young Person Abscond?*
    • Does your Child or Young Person have any phobias?*
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    • Medical Information 
    • Medical Information

      Medical Information

    • Does your Child or Young Person have any Allergies?*
    • Does your Child or Young Person have Asthma?*
    • Does your Child or Young Person have an emergency inhaler?*
    • Does your Child or Young Person have Epilepsy?*
    • Do they require Epilepsy medication?*
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    • Are there any other medical conditions we need to know about?*
    • Does the Child or Young Person take any medication?*
    • Befriending 
    • Befriending

      Befriending

      The befriending service is delivered by volunteers who meet with Children or Young People on a 1:1 basis.
    • Are you interested in your Child or Young Person having a Befriender?*

    • WHO IS THE BEFRIENDING SERVICE APPROPRIATE FOR?  THE SERVICE IS SUITABLE FOR DISABLED CHILDREN AND YOUNG PEOPLE WHO:

      • Are aged 5 to 18 years old
      • Can form an ongoing befriending relationship with a volunteer.
      • Have behaviour which allows a volunteer to look after them safely 1:1. 
      • Need or would benefit from 1:1 support to achieve more independence from their primary carers and take part in social and leisure activities
      • Have a parent or carer who would benefit from a short break.
      • Would ideally like a volunteer for between 2-4 hours a week on a regular basis.

      THE BEFRIENDERS ARE UNABLE TO:

      Help with intimate personal care or frequent help with lifting and moving. If in the home parent/carer can. 

      • Help with medication or medical procedures from their volunteer.
      • Have a home situation which would cause their volunteer to be unsafe when visiting (i.e. hygiene and basic safety standards within the home, risk to injury within the home etc.).
      • Need a volunteer to stay after midnight.
      • Are in crisis.

      We are not able to place a volunteer with a child who has unpredictable or unmanageable behaviour which could place them self and others at risk.

      There is no guarantee a suitable volunteer will be found and placed.

       

    • Volunteer Requirements

      To make sure we can try to source a volunteer who meets the needs of your family please let us know what you would require from a volunteer.
    • What age range would you like your volunteer to be?
    • Do you have any preference on gender of your volunteer?
    • Does your Child or Young Person want a Befriender?
    • Assessing Vulnerability and Prioritising Need Process  
    • Assessing Vulnerability and Prioritising Need Process

      Assessing Vulnerability and Prioritising Need Process

      We collect this information in order to help us prioritise children and young people who need the service the most
    • Please select all of the support services that you currently access*
    • Do you currently access any services from the Out and About Providers?*
    • What level of support does your child or young person require?
    • Does your child have an EHCP? (Educational, Health and Care Plan)*
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    • How often is your child or young person able to attend school or alternative education?*
    • Does your child or young person have any positive relationships with children or young people of their own age?*
    • Is your child experiencing any current challenges towards their identity?*
    • Do you feel like you need more support?*
    • Does your Child receive a Direct Payment*
    • Should be Empty: